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Psycho-​Oncology
Psycho-​Oncology
FOURTH EDITION

EDITED BY

William S. Breitbart, MD, FAPOS

Phyllis N. Butow, BA(Hons), DipEd, MClinPsych,
MPH, PhD
Paul B. Jacobsen, PhD
Wendy W. T. Lam, RN, PhD, FFPH
Mark Lazenby, APRN, PhD
Matthew J. Loscalzo, MSW, LCSW, FAPOS

1
3
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America.
© Oxford University Press 2021
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.
You must not circulate this work in any other form
and you must impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data
Names: Breitbart, William S., 1951– editor.
Title: Psycho-oncology / [edited by] William S. Breitbart, Phyllis N. Butow, Paul B. Jacobsen, Wendy W. T. Lam,
Mark Lazenby, Matthew J. Loscalzo ; senior editor, William Breitbart.
Other titles: Psycho-Oncology (Holland)
Description: 4th edition. | New York, NY : Oxford University Press, [2021] |
Includes bibliographical references and index.
Identifiers: LCCN 2020029603 (print) | LCCN 2020029604 (ebook) |
ISBN 9780190097653 (hardback) | ISBN 9780190097677 (epub) | ISBN 9780190097684
Subjects: MESH: Neoplasms—psychology | Risk Factors | Neoplasms—prevention & control |
Neoplasms—therapy
Classification: LCC RC262 (print) | LCC RC262 (ebook) | NLM QZ 260 |
DDC 616.99/40019—dc23
LC record available at https://lccn.loc.gov/2020029603
LC ebook record available at https://lccn.loc.gov/2020029604
DOI: 10.1093/​med/​9780190097653.001.0001
This material is not intended to be, and should not be considered, a substitute for medical or other professional
advice. Treatment for the conditions described in this material is highly dependent on the individual
circumstances. And, while this material is designed to offer accurate information with respect to the subject
matter covered and to be current as of the time it was written, research and knowledge about medical and health
issues is constantly evolving and dose schedules for medications are being revised continually, with new side
effects recognized and accounted for regularly. Readers must therefore always check the product information
and clinical procedures with the most up-​to-​date published product information and data sheets provided by
the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors
make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this
material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as
to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not
accept, and expressly disclaim, any responsibility for any liability, loss, or risk that may be claimed or incurred as a
consequence of the use and/​or application of any of the contents of this material.
9 8 7 6 5 4 3 2 1
Printed by LSC Communications, United States of America
Dedication: Jimmie C. Holland, M.D. (1928–2017)
Psycho-​Oncology, 4th edition is solemnly dedicated to Professor Jimmie C. Holland, MD (1928–​2017), internationally recognized as the founder
of the field of psycho-​oncology. Dr. Holland, who was affectionately known by her first name, “Jimmie,” had a profound global influence on the
fields of psycho-​oncology, oncology, supportive care, psychiatry, behavioral medicine, and psychosomatic medicine. At the time of her passing,
Dr. Holland was the Attending Psychiatrist and Wayne E. Chapman Chair at Memorial Sloan Kettering Cancer Center (MSK) and Professor of
Psychiatry, Weill Medical College of Cornell University in New York.
In 1977, Jimmie was appointed Chief of the Psychiatry Service in the Department of Neurology at MSK, by Jerome Posner, MD, then Chairman of
Neurology at MSK. The Psychiatry Service at MSK was the first such clinical, research, and training service established in any cancer center in the
world. In 1996, Dr. Holland was named the inaugural Chairwoman of the Department of Psychiatry and Behavioral Sciences at MSK—​again,
the first such department created in any cancer center in the U.S. or the world. Dr. Holland had over a 40-​year career at MSK.
Jimmie created and nurtured the field of psycho-​oncology, established its clinical practice, advanced its clinical research agenda, and, through
her pioneering efforts, launched the careers of the leaders of a worldwide field who continue to work in what has become a shared mission to em-
phasize “care” in cancer care. Dr. Holland founded the International Psycho-​Oncology Society (IPOS) in 1984 and the American Psychosocial
Oncology Society in 1986. Over 25 years ago, Jimmie founded the international journal Psycho-​Oncology and coedited the journal for 30 years.
Dr. Holland received many awards recognizing her achievements over the course of her career. Some of her notable awards include the Medal
of Honor for Clinical Research from the American Cancer Society, the Clinical Research Award from the American Association of Community
Cancer Centers, the American Association for Cancer Research Joseph H. Burchenal Clinical Research Award, the Marie Curie Award from the
Government of France, the Margaret L. Kripke Legend Award for contributions to the advancement of women in cancer medicine and cancer
science from the MD Anderson Cancer Center, the T. J. Martell Foundation 2015 Women of Influence Award, and the Distinguished Alumnus
Award from Baylor College of Medicine in 2016. She served as President of the Academy of Psychosomatic Medicine (APM) in 1996 and was the
recipient of the APM’s Hackett Lifetime Achievement Award in 1994. She was the inaugural recipient of the Arthur Sutherland Award for Lifetime
Achievement from IPOS.
This 4th edition of Psycho-​Oncology is the first edition of this text that has not been edited by Dr. Holland. In 1989, Dr. Holland edited the
Handbook of Psychooncology: Psychological Care of the Patient with Cancer, the first major textbook in our field. This landmark book was no-
table for several reasons; it established our “new” field, and it was the first use, in a text, of the term “psychooncology” to name our field (thankfully
the hyphen was soon added). Psycho-​oncology was thus born and named with the publication of this textbook. Subsequently, Dr. Holland edited,
with a group of dedicated coeditors, several editions of what became known as the “Bible” of psycho-​oncology or, in many circles, the “Holland
Textbook of Psycho-​oncology.” The textbook Psycho-​Oncology was published in 1998 and represented the most comprehensive, multidiscipli-
nary, and international encyclopedia of a field entering its adolescence. The year 2010 saw the publication of the 2nd edition, followed by the 3rd
edition in 2015, both published by Oxford University Press in collaboration with IPOS and APOS. Every card-​carrying “psycho-​oncologist” in
over 60 countries with national psycho-​oncology societies around the world had to have the latest edition in their library. For many it represented
a valued link to Jimmie Holland. The task of editing this 4th edition of Psycho-​Oncology without Jimmie’s firm guidance and wise counsel was
daunting for all of us, but we were all deeply inspired to do so because of our loving debt to Jimmie. The torch has been passed.
Dedication: Ruth McCorkle, PhD, RN, FAAN (1941–​2019)
In January 1975, a 33-​year-​old Ruth McCorkle, a newly minted PhD from the University of Iowa and a new assistant professor at the University of
Washington, met Jimmie C. Holland at a conference on the behavioral dimensions of cancer that was organized by the National Cancer Institute
in San Antonio, Texas. This meeting began a lifelong friendship and collaboration, not least of which was this book.
Ruth McCorkle died on August 17, 2019, in her home in Hamden, CT, from cancer. At the time of her death, she was the Florence Schorske Wald
Professor of Nursing Emerita at Yale University.
From the earliest days of her career, Ruth was interested in the lived experiences of people diagnosed with cancer, including the effects of touch on
the seriously ill and how the attachments and goals of patients undergoing treatment for lung cancer—​and their families—​changed over time. At
the University of Washington, she and Jeanne Quint-​Benoliel developed the first multidisciplinary cancer unit in which patients and their families
would be seen from the time of diagnosis through the dying experience by an interprofessional team.
It was on this unit, in the mid 1970’s, that she developed the first scale that measured the distress cancer patients experienced, the Symptom
Distress Scale. As a student of history, she learned of how Sir William Osler had taken field notes on his dying experience, in which he wrote that,
because he had “no actual pain,” he felt “singularly free from mental distress” as he was dying. In the early 1970’s, when Ruth had gone to London
to study with Dame Cicely Saunders at St. Christopher’s Hospice, she was introduced to the British psychiatrist J. M. Hinton and his now justly
famous qualitative work on associations between dying patients’ physical and mental distress. From Saunders and Hinton, and from Osler’s field
notes, Ruth began to see that patients’ mental distress could be related to their physical symptoms. She thus became interested in the points at
which a physical symptom becomes emotionally unbearable. Hence, her scale measured the presence of a symptom as well as how distressed a
patient was by it. The development of the Symptom Distress Scale led to her intervention.
She developed and tested in 7 National Institutes of Health-​funded clinical trials the Standardized Nursing Intervention Protocol, an intervention
in which an advanced practice cancer nurse helped patients and families learn to manage distressing symptoms. In a breakthrough, one of those
trials resulted in a 7-​month survival benefit.
We will read much about distress in this 4th edition of Psycho-​Oncology. For the importance of identifying and intervening on the sources of
cancer patients’ distress—​and even for the presence of the word “distress” in the psycho-​oncologic lexicon—​we have Ruth—​and Jimmie—​to thank.
Ruth ended the last article she wrote with this: “. . . patients’ physical needs must be addressed before their psychosocial problems are identified. It
is not just about taking care of their physical needs first. Rather, it is that we may be creating distress by not doing so.” Over the last 6 weeks of her
life, she instructed her hospice care providers on how to manage her physical needs, and her close friends and family provided the physical touch
she knew would comfort her emotionally. In this experience, one can find the truth of Ruth’s entire scientific career.
In this 4th edition of Psycho-​Oncology, you will find this truth woven into the science the book reports on: For Ruth, psycho-​oncology was not
just about how to support patients and families living with cancer. It was also about enabling them to have deaths “singularly free from mental
distress.” It is thus fitting that, along with Jimmie C. Holland, we dedicate this edition to Ruth McCorkle.
Contents

Section editors xiii 8 Cervical Cancer Screening and HPV

Contributors xv Vaccination: Multilevel Challenges to Cervical
Cancer Prevention 61
Introduction: Our Past, Our Future—New Richard Fielding, Samara Perez, Zeev Rosberger, Ovidiu Tatar,
Frontiers in Psycho-​Oncology 1 and Linda D. L. Wang
William S. Breitbart (Senior Editor)
9 Breast Cancer Screening 68
Gabriel M. Leung, Irene O. L. Wong, Ava Kwong, and
Joseph T. Wu
SECTION I
10 Prostate Cancer Screening 74
Behavioral and Psychological Factors in Michael A. Diefenbach, Daniel Nethala, Michael Schwartz, and
Cancer Risk and Prevention Simon J. Hall
Paul B. Jacobsen (Section Editor) 11 Lung Cancer Screening 78
1 Tobacco Use and Cessation 7 Lisa Carter-​Harris and Jamie Ostroff
Thomas H. Brandon, Vani N. Simmons, Úrsula Martínez, and 12 Skin Cancer Screening 87
Patricia Calixte-​Civil Jennifer L. Hay and Stephanie N. Christian
2 Diet and Cancer 13
Marian L. Fitzgibbon, Lisa Tussing-​Humphreys, Angela Kong,
and Alexis Bains
SECTION III
3 Physical Activity, Sedentary Behavior, and Screening and Testing for Germ Line and
Cancer 21
Somatic Mutations
Christine M. Friedenreich, Chelsea R. Stone, and Jessica McNeil
Paul B. Jacobsen (Section Editor)
4 Sun Exposure and Cancer Risk 30
Suzanne J. Dobbinson, Afaf Girgis, Bruce K. Armstrong, and 13 Psychosocial Issues in Genetic Testing for
Anne E. Cust Breast/​Ovarian Cancer 95
Mary Jane Esplen, Jonathan Hunter, and Eveline M. A. Bleiker
5 Psychosocial Factors 36
Anika von Heymann and Christoffer Johansen 14 Psychosocial Issues in Genetic Testing for
Hereditary Colorectal Cancer 102
6 Viral Cancers and Behavior 43 Sukh Makhnoon and Susan K. Peterson
Susan T. Vadaparampil, Lindsay N. Fuzzell, Shannon M. Christy,
Monica L. Kasting, Julie Rathwell, and Anna E. Coghill 15 Psychosocial Issues in Genomic Testing, Including
Genomic Testing for Targeted Therapies 110
Megan Best
SECTION II 16 Psychosocial Issues Related to Liquid Biopsy for
Screening for Cancer in Normal and At-​Risk ctDNA in Individuals at Normal and Elevated
Populations Risk 116
Jada G. Hamilton, Amanda Watsula-​Morley, and
Wendy W. T. Lam (Section Editor)
Alicia Latham
7 Colorectal Cancer Screening 53
Caitlin C. Murphy and Sally W. Vernon
viii Contents

29 Head and Neck Cancer 215

SECTION IV Loreto Fernández González, Jonathan Irish, and Gary Rodin
Screening and Assessment in Psychosocial 30 Central Nervous System Tumors 221
Oncology Alan D. Valentine
Wendy W. T. Lam (Section Editor) 31 HIV Infection and AIDS-​Associated
17 Screening and Assessment for Distress 121 Neoplasms 226
Alex J. Mitchell Joanna S. Dognin and Peter A. Selwyn

18 Assessment, Screening, and Case Finding

for Depression and Anxiety in People with
Cancer 130 SECTION VI
Kristine A. Donovan and Paul B. Jacobsen Management of Specific Physical
19 Screening for Delirium and Dementia in the Symptoms
Cancer Patient 137 William S. Breitbart (Section Editor)
Christian Bjerre-​Real, James C. Root, Yesne Alici,
Julia A. Kearney, and William S. Breitbart
32 Cancer-​Related Pain 235
R. Garrett Key, Dustin Liebling, Vivek T. Malhotra,
20 Screening and Assessment for Cognitive Steven D. Passik, Natalie Moryl, and William S. Breitbart
Problems 146
33 Nausea and Vomiting 255
Alexandra M. Gaynor, James C. Root, Elizabeth Ryan, and
Laura J. Lundi and Kavitha Ramchandran
Tim A. Ahles
34 Cancer-​Related Fatigue 265
Daniel C. McFarland, Christian Bjerre-​Real, Yesne Alici, and
William S. Breitbart
SECTION V
Psychological Issues Related to Site of 35 Sexual Problems and Cancer 276
Jeanne Carter, Ashley Arkema, Andrew J. Roth, Sally Saban, and
Cancer Christian J. Nelson
Mark Lazenby (Section Editor)
36 Neuropsychological Impact of Cancer and Cancer
21 Melanoma 155 Treatments 283
Nadine A. Kasparian and Iris Bartula Alexandra M. Gaynor, James C. Root, and Tim A. Ahles

22 Lung Cancer 162 37 Sleep and Cancer 291

Marianne Davies Amy E. Lowery-​Allison and E. Devon Eldridge-​Smith

23 Breast Cancer 169 38 Weight and Appetite Loss in Cancer 298

M. Tish Knobf and Youri Hwang Yesne Alici and Victoria Saltz

24 Colorectal Cancer 176 39 Body Image—​An Important Dimension in Cancer

Anne Miles and Claudia Redeker Care 303
Mary Jane Esplen and Michelle Cororve Fingeret
25 Prostate Cancer and Genitourinary
Malignancies 182
Andrew J. Roth and Alejandro Gonzalez-​Restrepo

26 Gastrointestinal Cancers 189

SECTION VII
Daniel C. McFarland and William S. Breitbart Psychiatric Disorders
27 Gynecologic Cancers 196 William S. Breitbart (Section Editor)
Heidi S. Donovan and Teresa H. Thomas 40 Adjustment Disorders in Cancer 313
28 Hematopoietic Dyscrasias and Stem Cell Froukje de Vries, Sarah Hales, Gary Rodin, and Madeline Li
Transplantation/​CAR-​T Cell Therapy 203 41 Depressive Disorders in Cancer 320
Jesse R. Fann and Nicole Bates Christian Schulz-​Quach, Madeline Li, Kimberley Miller, and
Gary Rodin
Contents ix

42 Suicide and Medical Aid in Dying 329 54 Mindfulness-​Based Interventions 429

Hayley Pessin, Elie Isenberg-​Grzeda, Reena Jaiswal, and Linda E. Carlson
Monique James
55 Acceptance and Commitment Therapy (ACT) for
43 Anxiety Disorders 338 Cancer Patients 438
Ashley M. Nelson, Chelsea S. Rapoport, Lara Traeger, and Nicholas J. Hulbert-​Williams, Ray Owen, and Christian J. Nelson
Joseph A. Greer
56 Supportive-​Expressive and Other Forms of Group
44 Delirium 345 Psychotherapy in Cancer Care 445
Yesne Alici and William S. Breitbart David W. Kissane
45 Substance Use Disorders 355 57 Emotion-​Focused Therapy 452
Sameer Hassamal, Adam Rzetelny, and Steven D. Passik Sharon Manne
46 Posttraumatic Stress Disorder Associated with 58 Interpersonal Psychotherapy and Cancer 459
Cancer Diagnosis and Treatment 363 Jennifer Sotsky, Hayley Pessin, and John C. Markowitz
Matthew Doolittle and Katherine N. DuHamel
59 Integrative Oncology 470
47 Psychiatric Toxicities of Cancer Therapies: Focus Santhosshi Narayanan, Gabriel Lopez, Jun J. Mao, Wenli Liu,
on Immunotherapy and Targeted Therapy 374 and Lorenzo Cohen
Daniel C. McFarland, Mehak Sharma, and Yesne Alici
Interventions for Families and Couples
60 Psychosocial Interventions for Couples and
SECTION VIII Families Coping with Cancer 481
Evidence-​Based Interventions Talia I. Zaider and David W. Kissane

William S. Breitbart and Phyllis N. Butow (Section Editors) Interventions for Advanced Cancer/​End of
Models of Care Delivery Life/​Bereavement

48 Delivering Integrated Psychosocial Oncology 61 Meaning-​Centered Psychotherapy 489

Care: The Collaborative Care Model 385 Melissa Masterson Duva, Wendy G. Lichtenthal,
Jesse R. Fann, Julia Ruark, and Michael Sharpe Allison J. Applebaum, and William S. Breitbart

49 The Engaged Patient: The Cancer Support 62 Dignity Therapy 495

Harvey Max Chochinov and Maia S. Kredentser
Community’s Comprehensive Model of
Psychosocial Programs, Services, and 63 Managing Cancer and Living Meaningfully
Research 393 (CALM) Therapy 502
Mitch Golant, Alexandra K. Zaleta, Susan Ash-​Lee, Sarah Hales and Gary Rodin
Joanne S. Buzaglo, Kevin Stein, M. Claire Saxton,
Marcia Donziger, Kim Thiboldeaux, and Linda Bohannon 64 Bereavement Interventions in the Setting of
Cancer Care 509
50 The Role of Implementation Science in Wendy G. Lichtenthal, Kailey E. Roberts, Holly G. Prigerson, and
Advancing Psychosocial Cancer Care 400 David W. Kissane
Paul B. Jacobsen and Wynne E. Norton
Interventions for Cancer Survivors
Interventions During Active Treatment
65 Meaning-​Centered Group Psychotherapy for
51 Supportive Psychotherapy in Cancer 409 Cancer Survivors 521
Rosangela Caruso, Maria Giulia Nanni, and Luigi Grassi Nadia van der Spek, Wendy G. Lichtenthal, Karen Holtmaat,
William S. Breitbart, and Irma M. Verdonck-​de Leeuw
52 Cognitive and Behavioral Interventions 416
Barbara L. Andersen, Nicole A. Arrato, and Caroline S. Dorfman 66 Physical Activity and Exercise Interventions in
53 Metacognitive Approaches 424 Cancer Survivors 528
Louise Sharpe and Leah Curran Chloe Grimmett, Rebecca J. Beeken, and Abigail Fisher
x Contents

Digital Health Interventions 76 Financial Toxicity in Cancer Treatment 616

Victoria Blinder and Francesca M. Gany
67 e-Health Interventions for Cancer Prevention
77 The Experience of Cancer as an Immigrant 621
and Control 537
Francesca M. Gany and Jennifer Leng
Kelly M. Shaffer, Elliot J. Coups,† and Lee M. Ritterband
78 Sexual and Gender Minority Health in
68 Digital Health Interventions for Psychosocial
Psycho-​Oncology 627
Distress (Anxiety and Depression) in Cancer 543
Charles Kamen and Jennifer M. Jabson Tree
Lisa Beatty and Haryana Dhillon

69 e-​Health Interventions for Physical Symptom

Control 550
Robert Zachariae
SECTION XII
Bio-​Behavioral Psycho-​Oncology
70 e-​Health Interventions for Tobacco
William S. Breitbart and Mark Lazenby (Section Editors)
Cessation 561
Chris Kotsen, Jamie Ostroff, and Lisa Carter-​Harris 79 Psycho-​Oncology, Stress Processes, and Cancer
Progression 637
Michael H. Antoni, Jennifer M. Knight, and Susan K. Lutgendorf
SECTION IX 80 Depression, Inflammation, and Cancer 644
Psychosocial Issues at the Time of Diagnosis Daniel C. McFarland, Leah E. Walsh, and Andrew H. Miller
Matthew J. Loscalzo (Section Editor) 81 Biobehavioral Psycho-​Oncology
71 Treatment Decision Making 573 Interventions 654
Allison Marziliano and Michael A. Diefenbach Michael A. Hoyt and Frank J. Penedo

72 The Family Meeting: Communication across the

Continuum of Cancer Care 578
Stefanie N. Mooney and Marinel Olivares SECTION XIII
Geriatric Psycho-​Oncology
Matthew J. Loscalzo (Section Editor)
SECTION X 82 The Older Cancer Patient 663
Palliative and Supportive Care Barbara A. Given and Charles W. Given
Mark Lazenby (Section Editor) 83 Geriatric Psycho-​Oncology Assessment Issues
73 Psychological and Psychiatric Aspects of Palliative and Interventions 671
and End-​of-​Life Care: Synergies between Psycho-​ Kelly M. Trevino, Rebecca M. Saracino, Andrew J. Roth,
Oncology and Palliative Care 589 Yesne Alici, and Christian J. Nelson
Scott A. Irwin, Nathan Fairman, Chase Samsel, Jeremy M. Hirst, 84 Communicating with the Older Adult Cancer
Jason A. Webb, and Manuel Trachsel Patient 678
74 Prognostic Understanding in Advanced Cancer Patricia A. Parker, Smita C. Banerjee, and Beatriz Korc-​Grodzicki
Patients 599
Laura C. Polacek, Leah E. Walsh, Allison J. Applebaum, and
Barry Rosenfeld
SECTION XIV
Pediatric Psycho-​Oncology
William S. Breitbart (Section Editor)
SECTION XI
Diversities in the Experience of Cancer 85 Screening and Assessment in Pediatric
Psycho-​Oncology 687
Matthew J. Loscalzo (Section Editor)
Darcy E. Burgers, Sarah J. Tarquini, Anne E. Kazak, and
75 Cancer, Culture, and Health Disparities 609 Anna C. Muriel
Marjorie Kagawa-​Singer and Annalyn Valdez-​Dadia
Contents xi

86 Psychiatric Disorders in Pediatric Psycho-​

Oncology: Diagnosis and Management 696 SECTION XVII
Julia A. Kearney, Meredith E. MacGregor, and Maryland Pao
Building Supportive Care/​Psycho-​Oncology
87 Evidence-​Based Psychosocial Interventions in Teams
Pediatric Psycho-​Oncology 703 Phyllis N. Butow (Section Editor)
Lori Wiener, Marie Barnett, Stacy Flowers, Cynthia Fair, and
Amanda L. Thompson Building Supportive Care Teams: Working
88 Adolescent and Young Adult Patients 715 Together and Self-​Care
Christabel K. Cheung, Sheila J. Santacroce, and Bradley J. Zebrack
96 Integrating Interdisciplinary Supportive Care
Programs: Transforming the Culture of Cancer
Care 775
SECTION XV Matthew J. Loscalzo, Karen L. Clark, Barry D. Bultz, and
Psychological Issues for the Family and Juee Kotwal

Caregivers 97 Occupational Stress in Oncology Staff: Burnout,

Phyllis N. Butow (Section Editor) Resilience, and Interventions 782
Fay J. Hlubocky and Daniel C. McFarland
89 Including Family Members in Caring for
the Patient with Cancer: A Family-​Centered Health Provider/​Patient Communication
Approach 723
Douglas S. Rait 98 Principles of Communication Skills Training
in Cancer Care across the Life Span and Illness
90 Couples Facing Cancer 729
Trajectory 791
Hoda Badr and Courtney Bitz
David W. Kissane and Carma L. Bylund
91 Cancer Caregivers 737
Allison J. Applebaum, Erin Kent, Kristin Litzelman, Betty Ferrell,
J. Nicholas Dionne-​Odom, and Laurel Northouse
SECTION XVIII
92 Addressing the Needs of Children When a Parent Psycho-​Oncology in Health Policy
Has Cancer 745
Cynthia W. Moore, Greer J. Dent, and Paula K. Rauch Wendy W. T. Lam (Section Editor)

99 Distress, the Sixth Vital Sign: A Catalyst for

Standardizing Psychosocial Care Globally 801
Barry D. Bultz, Matthew J. Loscalzo, Alex J. Mitchell, and
SECTION XVI
Jimmie C. Holland†
Survivorship
100 Implementation of Clinical Practice Guidelines
Phyllis N. Butow and Wendy W. T. Lam (Section Editors)
for Psychosocial Cancer Care 806
93 Fear of Cancer Recurrence 755 Jane Turner and Nicole Rankin
Allan B. Smith, Joanna E. Fardell, and Phyllis N. Butow
101 Emerging International Directions for
94 Implementing the Survivorship Care Plan: A Psychosocial Care: Perspectives from Asia and
Strategy for Improving the Quality of Care for Low-​Middle-​Income Countries 813
Cancer Survivors 760 Jeff Dunn, Melissa Henry, and Maggie Watson
Erin E. Hahn and Patricia A. Ganz
Index 819
95 Adult Survivors of Childhood Cancer 767
Lisa A. Schwartz, Claire E. Wakefield, Jordana K. McLoone,
Branlyn Werba DeRosa, and Anne E. Kazak
Section editors

William S. Breitbart, MD, FAPOS Wendy W. T. Lam, RN, PhD, FFPH

The Jimmie C. Holland Chair in Psychiatric Oncology Associate Professor, Head, Division of Behavioural Sciences,
Chairman School of Public Health
Department of Psychiatry and Behavioral Sciences Director, Jockey Club Institute of Cancer Care, Li Ka Shing
Memorial Sloan Kettering Cancer Center Faculty of Medicine
Professor of Clinical Psychiatry Director, Centre for Psycho-oncology Research and
Vice-Chairman Training (CePORT)
Department of Psychiatry The University of Hong Kong
Weill Cornell Medical College Mark Lazenby, APRN, PhD
President Emeritus, International Psycho-oncology Society Associate Dean for Faculty and Student Affairs
Phyllis N. Butow, BA(Hons), DipEd, MClinPsych, MPH, PhD Professor of Nursing and Philosophy
Professor of Psychological Medicine University of Connecticut School of Nursing
NHMRC Senior Principal Research Fellow Matthew J. Loscalzo, MSW, LCSW, FAPOS
Founding Chair, PoCoG Liliane Elkins Professor in Supportive Care Programs
School of Psychology Administrative Director, Sheri and Les Biller Patient and Family
University of Sydney Resource Center
Paul B. Jacobsen, PhD Executive Director, Department of Supportive Care Medicine
Associate Director Professor, Department of Population Sciences
Healthcare Delivery Research Program City of Hope National Medical Center
Division of Cancer Control and Population Sciences
National Cancer Institute
Contributors

Tim A. Ahles, PhD Hoda Badr, PhD

Attending Psychologist Associate Professor
Director, Neurocognitive Laboratory Department of Medicine
Psychiatry Service Baylor College of Medicine
Department of Psychiatry and Behavioral Sciences Houston, TX, USA
Member Alexis Bains, BSc Nutrition
Memorial Sloan Kettering Cancer Center Research Assistant
New York, NY, USA Department of Kinesiology and Nutrition
Yesne Alici, MD The University of Illinois at Chicago (UIC)
Associate Attending Psychiatrist Chicago, IL, USA
Clinical Director, Smita C. Banerjee, PhD
Co-​Director, Bio-​Behavioral Brain Clinic Associate Attending Behavioral Scientist
Psychiatry Service Behavioral Sciences Service
Department of Psychiatry and Behavioral Sciences Co-​Director, Comskils Laboratory
Memorial Sloan Kettering Cancer Center Department of Psychiatry and Behavioral Sciences
New York, NY, USA Memorial Sloan Kettering Cancer Center
Barbara L. Andersen, PhD New York, NY, USA
Distinguished University Professor Marie Barnett, PhD
Department of Psychology Assistant Attending Psychologist
Ohio State University Psychiatry Service
Columbus, OH, USA Department of Psychiatry and Behavioral Sciences &
Michael H. Antoni, PhD Department of Pediatrics
Professor Memorial Sloan Kettering Cancer Center
Department of Psychology New York, NY, USA
University of Miami and Sylvester Comprehensive Cancer Center Iris Bartula, DCP
Miami, FL, USA Head of Research Psychology
Allison J. Applebaum, PhD Melanoma Institute Australia
Assistant Attending Psychologist Senior Lecturer
Director, Caregiver’s Clinic Northern Sydney Medical School
Psychiatry Service Faculty of Medicine and Health
Department of Psychiatry and Behavioral Sciences University of Sydney
Memorial Sloan Kettering Cancer Center Sydney, NSW, Australia
New York, NY, USA Nicole Bates, MD
Ashley Arkema, MS Acting Assistant Professor
Nurse Practitioner Department of Psychiatry and Behavioral Sciences
Female Sexual Medicine University of Washington Attending Psychiatrist
Brooklyn, NY, USA Department of Psychosocial Oncology
Bruce K. Armstrong, BMedSci(Hons), MBBS(Hons), DPhil(Oxon), FRACP, FAFPHM Seattle Cancer Care Alliance
Retired Seattle, WA, USA
School of Population and Global Health Lisa Beatty, PhD
The University of Western Australia Senior Research Fellow
Perth, WA, Australia College of Medicine and Public Health
Nicole A. Arrato, MA Flinders University
Graduate Research Assistant Adelaide, SA, Australia
Department of Psychology Rebecca J. Beeken, PhD
Ohio State University Associate Professor of Behavioural Medicine
Columbus, OH, USA Leeds Institute of Health Sciences
Susan Ash-​Lee, MSW, LCSW University of Leeds
Vice President Leeds, Yorkshire, UK
Clinical Services Program
Cancer Support Community
Denver, CO, USA
xvi Contributors

Megan Best, PhD, MAAE, BMed(Hons), GradDipQHR Darcy E. Burgers, PhD

Senior Lecturer Psychologist
Department of Psycho-​Oncology Co-​operative Research Group Division of Pediatric Psychosocial Oncology
University of Sydney Department of Psychosocial Oncology and Palliative Care
Broadway, NSW, Australia Dana-​Farber Cancer Institute
Courtney Bitz, MSW, LCSW, OSW-​C Boston, MA, USA
Director of Clinical Social Work Phyllis N. Butow, BA(Hons), DipEd, MClinPsych, MPH, PhD
Department of Supportive Care Medicine Professor of Psychological Medicine
City of Hope NHMRC Senior Principal Research Fellow,
Duarte, CA, USA Founding Chair, PoCoG
Christian Bjerre-​Real, MD, MMCI School of Psychology
Research Fellow University of Sydney
Department of Psychiatry and Behavioral Sciences Sydney, NSW, Australia
Memorial Sloan Kettering Cancer Center Joanne S. Buzaglo, PhD
New York, NY, USA Executive Director, PRO Solutions
Eveline M. A. Bleiker, PhD Outcomes Sciences
Professor ConcertAI
Department of Psychosocial Research and Epidemiology Rydal, PA, USA
Netherlands Cancer Institute Carma L. Bylund, PhD
Amsterdam, The Netherlands Professor
Victoria Blinder, MD, MSc College of Journalism and Communications
Associate Attending Oncologist University of Florida
Associate Member Newberry, FL, USA
Immigrant Health and Cancer Disparities Service Patricia Calixte-​Civil, MA
Department of Psychiatry and Behavioral Sciences Doctoral Student
Breast Medicine Service Department of Psychology
Department of Medicine University of South Florida, Moffitt Cancer Center
Memorial Sloan Kettering Cancer Center Tampa, FL, USA
New York, NY, USA Linda E. Carlson, PhD
Linda Bohannon, MSM, BSN, RN Professor
President Department of Oncology
Global Headquarters University of Calgary
Cancer Support Community Cumming School of Medicine
Washington, DC, USA Calgary, AB, Canada
Thomas H. Brandon, PhD Jeanne Carter, PhD
Department Chair and Program Leader, Attending Psychologist
Health Outcomes and Behavior Director, Female Sexual Health Clinic
Moffitt Distinguished Scholar Gynecology Service
Director, Tobacco Research and Intervention Program Department of Surgery
Moffitt Cancer Center Psychiatry Service
Professor Department of Psychiatry and Behavioral Medicine
Departments of Psychology and Oncologic Sciences Memorial Sloan Kettering Cancer Center
University of South Florida New York, NY, USA
Tampa, FL, USA Lisa Carter-​Harris, PhD, APRN, ANP-​C , FAAN
William S. Breitbart, MD, FAPOS Associate Attending Behavioral Scientist
Jimmie C. Holland Chair in Psychiatric Oncology Behavioral Sciences Service
Chairman Department of Psychiatry and Behavioral Sciences
Department of Psychiatry and Behavioral Sciences Memorial Sloan Kettering Cancer Center
Member New York, NY, USA
Attending Psychiatrist Rosangela Caruso, MD, PhD
Supportive Care Service Doctor
Department of Medicine Biomedical and Specialty Surgical Sciences
Memorial Sloan Kettering Cancer Center University of Ferrara
Vice Chairman and Professor of Clinical Psychiatry Ferrara, Emilia Romagna, Italy
Department of Psychiatry
Christabel K. Cheung, PhD, MSW
Weill Cornell Medical College
Assistant Professor
New York, NY, USA
University of Maryland School of Social Work
Barry D. Bultz, AOE, PhD Member
Professor and Head, Division of Psychosocial Oncology University of Maryland Greenbaum Comprehensive Cancer Center
Daniel Family Leadership Chair in Psychosocial Oncology Baltimore, MD, USA
Department of Oncology
Harvey Max Chochinov, OM, OC, PhD, MD, FRCPC, FRSC, FCAHS
Cumming School of Medicine
Distinguished Professor
Department of Psychosocial Oncology
Department of Psychiatry
Tom Baker Cancer Center
University of Manitoba
University of Calgary
Winnipeg, MB, Canada
Calgary, AB, Canada
Contributors xvii

Stephanie N. Christian, MPH Haryana Dhillon, BSc, MA(Psych), PhD

K. Leroy Irvis Fellow Associate Professor
Department of Behavioral and Community Health Sciences Centre for Medical Psychology and Evidence-​based Decision-​making,
University of Pittsburgh Graduate School of Public Health School of Psychology, Faculty of Science
Pittsburgh, PA, USA The University of Sydney
Shannon M. Christy, PhD Camperdown, NSW, Australia
Department of Health Outcomes and Behavior Michael A. Diefenbach, PhD
Division of Population Science H. Lee Moffitt Cancer Center and Research Professor
Institute Departments of Medicine, Urology and Psychiatry
Department of Oncologic Sciences Northwell Health
Morsani College of Medicine University of South Florida Manhasset, NY, USA
Center for Immunization and Infection Research in Cancer J. Nicholas Dionne-​Odom, PhD, RN, ACHPN
Lee Moffitt Cancer Center and Research Institute Assistant Professor
Tampa, FL, USA School of Nursing
Karen L. Clark, MS University of Alabama at Birmingham
Manager of Supportive Care Programs Hoover, AL, USA
Department of Supportive Care Medicine Suzanne J. Dobbinson, BSc, MSc, PhD
City of Hope National Medical Center Senior Research Fellow
Duarte, CA, USA Centre for Behavioural Research in Cancer
Anna E. Coghill, PhD, MPH Cancer Council Victoria
Assistant Member Kensington, VIC, Australia
Cancer Epidemiology Joanna S. Dognin, PsyD
Moffitt Cancer Center Psychologist
Tampa, FL, USA Department of Veterans Affairs
Lorenzo Cohen, PhD NYU Langone Medical Center
Professor and Director, Integrative Medicine Program White Plains, NY, USA
Department of Palliative, Rehabilitation and Integrative Medicine Heidi S. Donovan, PhD, RN
The University of Texas MD Anderson Cancer Center Professor
Houston, TX, USA Co-​Director National Rehabilitation Research and Training Center
Elliot J. Coups, PhD† on Family Support
Member Department of Health and Community Systems
Rutgers Cancer Institute of New Jersey University of Pittsburgh
Department of Medicine Pittsburgh, PA, USA
Rutgers Robert Wood Johnson Medical School Kristine A. Donovan, PhD, MBA
Rutgers, The State University of New Jersey Associate Member
New Brunswick, NJ, USA Department of Supportive Care Medicine
Leah Curran, DCP Moffitt Cancer Center
Clinical Psychologist Tampa, FL, USA
Department of Psychology Marcia Donziger, BA
The University of Sydney Vice President
Camperdown, NSW, Australia Digital Strategy and Business Development
Anne E. Cust, PhD, MPH(Hons), BSc, BA Cancer Support Community
Professor of Cancer Epidemiology Denver, CO, USA
Sydney School of Public Health Matthew Doolittle, MD
And the Melanoma Institute Australia Assistant Attending Psychiatrist
The University of Sydney Psychiatry Service
Camperdown, NSW, Australia Department of Psychiatry and Behavioral Sciences
Marianne Davies, DNP, ACNP, AOCNP Memorial Sloan Kettering Cancer Center
Associate Professor Yale School of Nursing New York, NY, USA
Department of Oncology Nurse Practitioner Caroline S. Dorfman, PhD
Smilow Cancer Hospital Assistant Professor
New Haven, CT, USA Department of Psychiatry and Behavioral Sciences
Greer J. Dent, BA Duke University Medical Center
Clinical Research Coordinator Durham, NC, USA
Department of Cancer Center Katherine N. DuHamel, PhD
Massachusetts General Hospital Director
Boston, MA, USA KND Consulting
Branlyn Werba DeRosa, PhD New York, NY, USA
Research Director Jeff Dunn, PhD, AO
Department of Research and Training Institute Professor
Cancer Support Community Department of Research and Innovation
Ardmore, PA, USA University of Southern Queensland
Toowoomba, Queensland, Australia
xviii Contributors

E. Devon Eldridge-​Smith, PhD Marian L. Fitzgibbon, PhD

Assistant Professor Professor
Department of Medicine Department of Pediatrics
National Jewish Health University of Illinois
Denver, CO, USA Chicago, IL, USA
Mary Jane Esplen, PhD Stacy Flowers, PsyD
Professor and Vice-​Chair Associate Professor
Department of Psychiatry Director of Behavioral Science
Faculty of Medicine Department of Family Medicine
University of Toronto Wright State University
Toronto, ON, Canada Columbus, OH, USA
Cynthia Fair, LCSW, MPH, DrPH Christine M. Friedenreich, PhD, FCAHS, FRSC
Professor and Department Chair Scientific Director
Department of Public Health Studies Department of Cancer Epidemiology and Prevention Research
Elon University Alberta Health Services
Elon, NC, USA Arnie Charbonneau Cancer Institute
Nathan Fairman, MD, MPH Adjunct Professor
Associate Clinical Professor The Faculties of Medicine and Kinesiology
Department of Psychiatry and Behavioral Sciences University of Calgary
UC Davis School of Medicine Calgary, AB, Canada
Sacramento, CA, USA Lindsay N. Fuzzell, PhD
Jesse R. Fann, MD, MPH Applied Research Scientist I
Professor Health Outcomes and Behavior
Department of Psychiatry and Behavioral Sciences Moffitt Cancer Center
Adjunct Professor Tampa, FL, USA
Departments of Rehabilitation Medicine and Epidemiology Francesca M. Gany, MD, MS
University of Washington Attending Physician
Medical Director Chief, Immigrant Health and Cancer Disparities Service
Department of Psychosocial Oncology Department of Psychiatry and Behavioral Sciences
Seattle Cancer Care Alliance Clinical Research Division Member
Fred Hutchinson Cancer Research Center Seattle, Washington Memorial Sloan Kettering Cancer Center
Seattle, WA, USA Professor
Joanna E. Fardell, PhD, MClinNeuropsych, BSc Department of Medicine and Department of Healthcare Policy & Research
Research Fellow Weill Cornell Medicine
Department of Behavioural Sciences Unit, Discipline of Paediatrics, New York, NY, USA
School of Women’s and Children’s Health, Faculty of Medicine Patricia A. Ganz, MD
University of New South Wales Distinguished Professor
Randwick, NSW, Australia Schools of Medicine and Public Health
Loreto Fernández González, BA, BSc, MPH University of California, Los Angeles (UCLA)
PhD Student and Connaught Scholar Los Angeles, CA, USA
Social and Behavioural Health Sciences Alexandra M. Gaynor, PhD
Dalla Lana School of Public Health Post-​Doctoral Neuropsychology Research Fellow
University of Toronto Department of Psychiatry and Behavioral Sciences
Toronto, ON, Canada Memorial Sloan Kettering Cancer Center
Betty Ferrell, RN, PhD, FAAN New York, NY, USA
Professor Afaf Girgis, PhD, BSc(Hons)
Nursing Research Professor
City of Hope National Medical Center Director, Psycho-​Oncology Research Group
Duarte, CA, USA University of New South Wales
Richard Fielding, BA(Hons), CPsychol, PhD, FFPH, FHKPsyS Sydney, Australia
Clinical Lead Barbara A. Given, PhD, RN, FAAN
Jockey Club Institute of Cancer Care, Li Ka Shing Faculty of Medicine University Distinguished Professor, Associate Dean Emeritus
Honorary Professor, School of Public Health College of Nursing
The University of Hong Kong Michigan State University
Hong Kong, China Okemos, MI, USA
Michelle Cororve Fingeret, PhD Charles W. Given, PhD
Fingeret Psychology Services Professor Emeritus
Houston, TX, USA College of Nursing
Abigail Fisher, PhD Michigan State University
Associate Professor Okemos, MI, USA
Department of Behavioural Science and Health Mitch Golant, PhD
University College London Senior Consultant, Strategic Initiatives
Bloomsbury, London, UK Research and Training Institute
Cancer Support Community
Los Angeles, CA, USA
Contributors xix

Alejandro Gonzalez-​Restrepo, MD Melissa Henry, PhD

Attending Psychiatrist Associate Professor
Hartford Hospital/​Institute of Living Department of Oncology
Hartford Healthcare Faculty of Medicine
Simsbury, CT, USA McGill University
Luigi Grassi, MD Montreal, QC, Canada
Professor and Chair of Psychiatry Anika von Heymann, MSc, Psych, PhD
University of Ferrara Postdoctoral Fellow
Chairman of the Department of Biomedical and Specialty Surgical Sciences Department of Oncology
University of Ferrara Rigshospitalet
Ferrara, Italy København, Denmark
Joseph A. Greer, PhD Jeremy M. Hirst, MD
Associate Professor of Psychology Clinical Professor of Psychiatry; Palliative Care Psychiatry
Department of Psychiatry Department of Psychiatry; Palliative Medicine
Harvard Medical School UC San Diego School of Medicine
Program Director, Center for Psychiatric Oncology & La Jolla, CA, USA
Behavioral Sciences Fay J. Hlubocky, PhD, MA, CCTP
Massachusetts General Hospital Cancer Center Clinical Health Psychologist
Boston, MA, USA Research Project Professor
Chloe Grimmett, PhD Department of Medicine
Senior Research Fellow University of Chicago Medicine
School of Health Sciences Chicago, IL, USA
University of Southampton Jimmie C. Holland, MD†
Hampshire, UK Wayne E. Chapman Chair in Psychiatric Oncology
Erin E. Hahn, PhD, MPH Attending Psychiatrist
Research Scientist Psychiatry Service
Department of Research and Evaluation Department of Psychiatry and Behavioral Sciences
Kaiser Permanente Southern California Member
Pasadena, CA, USA Memorial Sloan Kettering Cancer Center
Sarah Hales, MD, PhD New York, NY, USA
Assistant Professor Karen Holtmaat, MSc, MA
Division of Psychosocial Oncology Assistant Professor in Psychosocial Oncology
Department Supportive Care Department of Clinical, Neuro-​and Developmental Psychology
Princess Margaret Cancer Centre Vrije Universiteit Amsterdam
Centre for Mental Health Amsterdam, NH, The Netherlands
University Health Network Michael A. Hoyt, PhD
University of Toronto Associate Professor
Toronto, ON, Canada Chao Cancer Center
Simon J. Hall, MD UC Irvine
Zucker Professor of Urologic Oncology Irvine, CA, USA
Smith Institute of Urology Nicholas J. Hulbert-​Williams, BSc, PhD, CPsychol, APBPsS, FHAE
Hofstra Northwell School of Medicine Professor of Behavioural Medicine
Lake Success, NY, USA School of Psychology
Jada G. Hamilton, PhD, MPH University of Chester
Assistant Attending Psychologist Chester, UK
Behavioral Sciences Service Jonathan Hunter, BSc, MD, FRCPC
Department of Psychiatry and Behavioral Sciences; Department of Medicine Professor
Assistant Member Department of Psychiatry
Memorial Sloan Kettering Cancer Center University of Toronto
New York, NY, USA Toronto, ON, Canada
Sameer Hassamal, MD Youri Hwang, MSN, RN, FNP-​C
Assistant Professor PhD Student
Department of Psychiatry School of Nursing
Arrowhead Regional Medical Center Yale University
Colton, CA, USA New Haven, CT, USA
Jennifer L. Hay, PhD Jonathan Irish, MD, MSc, FRCSC, FACS
Attending Psychologist Professor and Head
Behavioral Sciences Service Division of Head and Neck Oncology and Reconstructive Surgery
Department of Psychiatry and Behavioral Sciences Department of Otolaryngology-​Head and Neck Surgery
Member Princess Margaret Cancer Centre, University of Toronto
Memorial Sloan Kettering Cancer Center Toronto, ON, Canada
New York, NY, USA
xx Contributors

Scott A. Irwin, MD, PhD, FACLP, FAPA Anne E. Kazak, PhD, ABPP
Professor of Psychiatry and Behavioral Neurosciences Editor-​in-​Chief, American Psychologist
Department of Psychiatry and Behavioral Neurosciences Director, Center for Healthcare Delivery Science
Director of Patient and Family Support Program Nemours Children’s Health System Co-​Director
Samuel Oschin Comprehensive Cancer Institute, Center for Pediatric Traumatic Stress Professor
Cedars-​Sinai Health System Department of Pediatrics
Los Angeles, CA, US Thomas Jefferson University
Elie Isenberg-​Grzeda, MD, CM, FRCPC Wilmington, DE, USA
Assistant Professor Julia A. Kearney, MD
Department of Psychiatry Assistant Attending Psychiatrist
University of Toronto Clinical Director, Pediatric Psycho-​Oncology Program
Toronto, ON, Canada Department of Psychiatry and Behavioral Sciences &
Jennifer M. Jabson Tree, PhD, MPH Department of Pediatrics
Associate Professor Memorial Sloan Kettering Cancer Center
Department of Public Health New York, NY, USA
University of Tennessee Erin Kent, PhD, MS
Knoxville, TN, USA Associate Professor
Paul B. Jacobsen, PhD Health Policy and Management
Associate Director University of North Carolina
Division of Cancer Control and Population Sciences Chapel Hill, NC, USA
National Cancer Institute R. Garrett Key, MD, FAPA, FACLP
Bethesda, MD, USA Assistant Professor
Reena Jaiswal, MD Psychiatry and Behavioral Sciences
Assistant Attending Psychiatrist University of Texas at Austin Dell Medical School
Psychiatry Service Austin, TX, USA
Department of Psychiatry and Behavioral Sciences David W. Kissane, AC, MBBS, MPM, MD, FRANZCP, FAChPM, FACLP
Memorial Sloan Kettering Cancer Center UNDA Chair of Palliative Medicine Research
New York, NY, USA Cunningham Centre for Palliative Care, St Vincent’s Sydney
Monique James, MD University of Notre Dame Australia
Assistant Attending Psychiatrist Head of Szalmuk Family Psycho-​oncology Research Unit
Psychiatry Service Department of Palliative Care
Department of Psychiatry and Behavioral Sciences Cabrini Health, Melbourne, Australia
Memorial Sloan Kettering Cancer Center Head of Psycho-​Oncology Clinic
New York, NY, USA Monash Medical Centre
Monash University
Christoffer Johansen, MD, PhD, Dr. Med. Sci.
Clayton, VIC, Australia
Professor
Head, CASTLE—​Cancer Late Effect Research Oncology Clinic Jennifer M. Knight, MD, MS
Department of Oncology Associate Professor
Center for Surgery and Cancer Department of Psychiatry, Medicine, and Microbiology and Immunology
Rigshospitalet Medical College of Wisconsin
Copenhagen, Denmark Shorewood, WI, USA

Marjorie Kagawa-​Singer, PhD, MA, MN, RN M. Tish Knobf, PhD, RN, FAAN
Research Professor Professor
Community Health Sciences Department of Nursing
University of California, Los Angeles (UCLA) Yale University
Los Angeles, CA, USA New Haven, CT, USA
Charles Kamen, PhD, MPH Angela Kong, PhD, MPH, RD
Assistant Professor Assistant Professor
Department of Surgery Department of Pharmacy Systems, Outcomes, and Policy
University of Rochester University of Illinois Chicago
Rochester, NY, USA Chicago, IL, USA

Nadine A. Kasparian, PhD Beatriz Korc-​Grodzicki, MD, PhD, FAGS

Professor of Pediatrics Director, Cincinnati Children’s Center for Heart Disease Chief, Geriatrics Service
and Mental Health Heart Institute and Division of Behavioral Medicine and Department of Medicine
Clinical Psychology Memorial Sloan-​Kettering Cancer Center
Department of Pediatrics Professor of Medicine
University of Cincinnati College of Medicine Weill Cornell Medical College
Cincinnati, OH, USA New York, NY, USA

Monica L. Kasting, PhD Chris Kotsen, PsyD, NCTTP

Assistant Professor Associate Attending Psychologist
Department of Public Health Associate Director, Tobacco Treatment Program
Purdue University Department of Psychiatry and Behavioral Sciences
West Lafayette, IN, USA Memorial Sloan Kettering Cancer Center
New York, NY, USA
Contributors xxi

Juee Kotwal, MBS, PMP Kristin Litzelman, PhD

Business Manager Assistant Professor
Department of Supportive Care Medicine Department of Human Development and Family Studies
City of Hope National Medical Center University of Wisconsin-​Madison
Duarte, CA, USA Madison, WI, USA
Maia S. Kredentser, PhD Wenli Liu, MD
Research Fellow Associate Professor
Clinical Health Psychology Department of Palliative, Rehabilitation and Integrative Medicine
University of Manitoba MD Anderson Cancer Center
Winnipeg, MB, Canada Houston, TX, USA
Ava Kwong, MBBS, BSc, PhD, FRCS, FRCS, FHKAM, FCSHK Gabriel Lopez, MD
Clinical Professor Associate Professor, Center Medical Director
Division of Breast Surgery, Department of Surgery Department of Palliative, Rehabilitation, and Integrative Medicine
The University of Hong Kong Li Ka Shing Faculty of Medicine University of Texas, MD Anderson Cancer Center
Pok Fu Lam, Hong Kong, China Houston, TX, USA
Wendy W. T. Lam, RN, PhD, FFPH Matthew J. Loscalzo, MSW, LCSW, FAPOS
Associate Professor, Head, Division of Behavioural Sciences, School of Liliane Elkins Professor in Supportive Care Programs
Public Health Administrative Director, Sheri & Les Biller Patient and Family
Director, Jockey Club Institute of Cancer Care, Li Ka Shing Faculty of Medicine Resource Center
Director, Centre for Psycho-​oncology Research and Training (CePORT) Executive Director, Department of Supportive Care Medicine
The University of Hong Kong Professor, Department of Population Sciences
Hong Kong, China City of Hope National Medical Center
Duarte, CA, USA
Alicia Latham, MD
Amy E. Lowery-​Allison, PhD
Assistant Attending Physician
Associate Attending Psychologist
Department of Medicine
Psychiatry Service
Memorial Sloan Kettering Cancer Center
Department of Psychiatry and Behavioral Sciences
New York, NY, USA
Memorial Sloan Kettering Cancer Center
Mark Lazenby, APRN, PhD New York, NY, USA
Professor of Nursing and Philosophy
Laura J. Lundi, BS
Associate Dean for Faculty and Student Affairs
Administrative Clinical Research Coordinator
University of Connecticut School of Nursing
Department of Medicine
Storrs, CT, USA
Stanford University
Jennifer Leng, MD, MPH Stanford, CA, USA
Associate Attending Physician Susan K. Lutgendorf, PhD
Associate Member Professor and Starch Faculty Fellow
Immigrant Health and Cancer Disparities Service Departments of Psychological and Brain Sciences, Obstetrics and Gynecology,
Department of Psychiatry and Behavioral Sciences and Urology
Memorial Sloan Kettering Cancer Center University of Iowa
New York, NY, USA Iowa City, IA, USA
Gabriel M. Leung, MD Irma M. Verdonck-​de Leeuw, PhD
Dean of Medicine Full Professor in Psychosocial Oncology
LKS Faculty of Medicine Department of Otolaryngology/​Head and Neck Surgery
The University of Hong Kong Vrije University Medical Center/​Cancer Center Amsterdam
Pok Fu Lam, Hong Kong Section of Clinical, Neuro-​and Developmental Psychology
Madeline Li, MD, PhD, FRCP(C) Vrije Universiteit Amsterdam
Attending Psychiatrist Amsterdam, The Netherlands
Department of Supportive Care Meredith E. MacGregor, MD
Princess Margaret Cancer Centre Assistant Attending Psychiatrist
University Health Network Department of Child and Adolescent Psychiatry and Behavioral Sciences
Associate Professor Children’s Hospital of Philadelphia
Department of Psychiatry Philadelphia, PA, USA
Faculty of Medicine Sukh Makhnoon, PhD, MS
University of Toronto Postdoctoral Fellow
Toronto, ON, Canada Department of Behavioral Science
Wendy G. Lichtenthal, PhD, FT University of Texas MD Anderson Cancer Center
Associate Attending Psychologist Houston, TX, USA
Director, Bereavement Clinic, Vivek T. Malhotra, MD, MPH
Psychiatry Service Chief, Anesthesiology Pain Service
Department of Psychiatry and Behavioral Sciences Associate Attending
Memorial Sloan Kettering Cancer Center Department of Anesthesiology and Critical Care Medicine
New York, NY, USA Memorial Sloan Kettering Cancer Center
Dustin Liebling, MD New York, NY, USA
Clinical Fellow Sharon Manne, PhD
Anesthesia Pain Management Service Section Chief, Professor of Medicine
Department of Anesthesiology and Critical Care Medicine Department of CINJ, Behavioral Sciences
Memorial Sloan Kettering Cancer Center Rutgers, The State University of New Jersey
New York, NY, USA New Brunswick, NJ, USA
xxii Contributors

Jun J. Mao, MD, MSCE Alex J. Mitchell, MBBS, MSc, MD, MRCPsych
Laurance S. Rockefeller Chair in Integrative Medicine Professor
Chief, Integrative Medicine Service Department of Psycho-​Oncology and Cancer Care
Attending Physician University of Leicester
Department of Medicine Leicester, UK
Memorial Sloan Kettering Cancer Center, Bendheim Integrative Medicine Center Stefanie N. Mooney, MD
New York, NY, USA Assistant Clinical Professor of Medicine
John C. Markowitz, MD Division of Supportive Medicine
Research Psychiatrist Department of Supportive Care Medicine
New York State Psychiatric Institute City of Hope National Medical Center
Professor of Clinical Psychiatry Duarte, CA, USA
Columbia University College of Physicians and Surgeons Cynthia W. Moore, PhD
New York, NY, USA Psychologist
Úrsula Martínez, PhD Department of Child and Adolescent Psychiatry
Applied Research Scientist Massachusetts General Hospital
Department of Health Outcomes and Behavior Boston, MA, USA
H. Lee Moffitt Cancer Center and Research Institute
Natalie Moryl, MD
Tampa, FL, USA
Associate Attending Physician
Allison Marziliano, PhD Supportive Care Service
Postdoctoral Fellow Department of Medicine
Department of Medicine Memorial Sloan Kettering Cancer Center
Northwell Health Associate Professor
Bethpage, NY, USA Department of Medicine
Melissa Masterson Duva, PhD Weill Cornell Medical College
Senior Psychologist New York, NY, USA
WTC Health Program Clinical Center of Excellence Anna C. Muriel, MD, MPH
New York University School of Medicine Chief, Division of Pediatric Psychosocial Oncology
New York, NY, USA Associate Psychiatrist
Daniel C. McFarland, DO Department of Psychosocial Oncology and Palliative Care
Research Fellow Dana Farber Cancer Institute
Department of Psychiatry and Behavioral Sciences Assistant Professor of Psychiatry
Memorial Sloan Kettering Cancer Center Harvard Medical School
New York, NY, USA Boston, MA, USA
Jordana K. McLoone, PhD Caitlin C. Murphy, PhD, MPH
Post-​Doctoral Research Fellow Assistant Professor
Women’s and Children’s Health, Faculty of Medicine Department of Population and Data Sciences
University of New South Wales UT Southwestern Medical Center
NSW, Australia Dallas, TX, USA
Jessica McNeil, PhD
Maria Giulia Nanni, MD
Postdoctoral Fellow Associate Professor
Cancer Epidemiology and Prevention Research Department of Biomedical and Specialty Surgical Sciences
Alberta Health Services University of Ferrara
Russell, ON, Canada Ferrara, Italy
Anne Miles, BSc, PhD
Santhosshi Narayanan, MD
Reader in Psychology
Assistant Professor
Department of Psychological Sciences
Department of PRIM
Birkbeck, University of London
MD Anderson Cancer Center
Bloomsbury, London, UK
Houston, TX, USA
Andrew H. Miller, MD
Ashley M. Nelson, PhD
William P. Timmie Professor of Psychiatry and Behavioral Sciences
Postdoctoral Fellow
Department of Psychiatry and Behavioral Sciences
Department of Psychiatry
Emory University School of Medicine
Massachusetts General Hospital/​Harvard Medical School
Atlanta, GA, USA
Boston, MA, USA
Kimberley Miller, MD, FRCPC
Attending Psychiatrist Christian J. Nelson, PhD
Department of Supportive Care Chief, Psychiatry Service,
Princess Margaret Cancer Centre, Associate Attending Psychologist
University Health Network Department of Psychiatry and Behavioral Sciences
Assistant Professor of Psychiatry Associate Member
Department of Psychiatry Memorial Sloan Kettering Cancer Center
Faculty of Medicine New York, NY, USA
University of Toronto
Toronto, ON, Canada
Contributors xxiii

Daniel Nethala, MD Hayley Pessin, PhD

Resident Psychologist
Department of Urology Department of Psychiatry and Behavioral Sciences
Smith Institute for Urology at Northwell Health Memorial Sloan Kettering Cancer Center
Lake Success, NY, USA New York, NY, USA
Laurel Northouse, PhD Susan K. Peterson, PhD, MPH
Professor Emerita Professor
School of Nursing Department of Behavioral Science
University of Michigan The University of Texas MD Anderson Cancer Center
Ann Arbor, MI, USA Houston, TX, USA
Wynne E. Norton, PhD Laura C. Polacek, MA
Program Director Graduate Student
Division of Cancer Control and Population Sciences Department of Psychology
National Cancer Institute Fordham University
Bethesda, MD, USA The Bronx, NY, USA
Marinel Olivares, LCSW, ACHP-​SW Holly G. Prigerson, PhD
Clinical Social Worker Irving Sherwood Wright Professor in Geriatrics
Adult Hematology/​Hematopoietic Cell Transplantation Professor of Sociology in Medicine
Director, Family Meeting Program Director
Department of Supportive Care Medicine Cornell Center for Research on End-​of-​Life Care
City of Hope National Medical Center New York, NY, USA
Duarte, CA Douglas S. Rait, PhD
Jamie Ostroff, PhD Clinical Professor of Psychiatry and Behavioral Sciences
Chief, Behavioral Sciences Service Chief, Couples and Family Therapy Clinic
Vice Chair for Research Department of Psychiatry and Behavioral Sciences
Member and Attending Psychologist Stanford University
Director, Tobacco Treatment Program Stanford, CA, USA
Department of Psychiatry and Behavioral Sciences Kavitha Ramchandran, MD
Memorial Sloan Kettering Cancer Center Clinical Associate Professor
New York, NY, USA Department of Medicine
Ray Owen, DClinPsych, Cpsychol, FHEA Stanford University
Consultant Clinical Psychologist Stanford, CA, USA
Health Psychology Department Nicole Rankin, BA(Hons), MSc, PhD
Wye Valley NHS Trust Senior Research Fellow
Hereford, UK Faculty of Medicine and Health
Maryland Pao, MD The University of Sydney
Clinical and Deputy Scientific Director Camperdown, NSW, Australia
Department of NIMH Chelsea S. Rapoport, BA
National Institutes of Health (NIH) Clinical Research Coordinator
Bethesda, MD, USA Department of Psychiatry
Patricia A. Parker, PhD Massachusetts General Hospital
Attending Psychologist Boston, MA, USA
Behavioral Sciences Service Julie Rathwell, MPH
Director, Communication Skills Training and Research Program Research Project Specialist, Sr.
Department of Psychiatry and Behavioral Sciences Department of Cancer Epidemiology
Member, Memorial Hospital Moffitt Cancer Center
Memorial Sloan-​Kettering Cancer Center Tampa, FL, USA
New York, NY, USA
Paula K. Rauch, MD
Steven D. Passik, PhD Director, Marjorie E. Korff Parenting at a Challenging Time Program
Vice President, Department of Psychiatry
Scientific Affairs, Education and Policy Massachusetts General Hospital
Collegium Pharmaceuticals Boston, MA, USA
Stoughton, MA, USA
Claudia Redeker, MSc
Frank J. Penedo, PhD PhD Student
Professor Department of Psychology
Department of Psychology and Medicine Birkbeck College
University of Miami Bloomsbury, London, UK
Miami, FL, USA
Lee M. Ritterband, PhD
Samara Perez, PhD Professor
Research Associate Department of Psychiatry and Neurobehavioral Sciences
Department Lady Davis Institute for Medical Research Jewish University of Virginia
General Hospital Charlottesville, VA, USA
Clinical Psychologist
Psychosocial Oncology Program
McGill University Health Center
Montreal, QC, Canada
xxiv Contributors

Kailey E. Roberts, PhD Sally Saban, BA

Research Fellow Clinic Research Coordinator
Department of Psychiatry and Behavioral Sciences Department of Surgery
Memorial Sloan Kettering Cancer Center New York, NY, USA
New York, NY, USA Victoria Saltz
Gary Rodin, MD Student
Head of Department Williams College
Department of Supportive Care New York, NY, USA
Princess Margaret Cancer Centre Chase Samsel, MD
University Health Network Attending Physician
Professor Department of Psychiatry
Department of Psychiatry Boston Children’s Hospital and Dana-​Farber Cancer Institute
Faculty of Medicine Boston, MA, USA
Director
Sheila J. Santacroce, PhD, RN, CPNP, FAANP
Global Institute of Psychosocial, Palliative and End-​of-​Life Care
Associate Professor
University of Toronto
School of Nursing
Toronto, ON, Canada
University of North Carolina
James C. Root, PhD Chapel Hill, NC, USA
Associate Attending Neuropsychologist
Rebecca M. Saracino, PhD
Psychiatry Service
Assistant Attending Psychologist
Department of Psychiatry and Behavioral Sciences
Psychiatry Service
Memorial Sloan Kettering Cancer Center
Department of Psychiatry and Behavioral Sciences
New York, NY, USA
Memorial Sloan Kettering Cancer Center
Zeev Rosberger, PhD New York, NY, USA
Senior Investigator and Associate Professor
M. Claire Saxton, MBA
Departments of Oncology, Psychiatry, and Psychology
Vice President
Lady Davis Institute for Medical Research
Department of Education and Outreach
Institute of Community and Family Psychiatry
Cancer Support Community
Jewish General Hospital
Washington, DC, USA
Gerald Bronfman Department of Oncology
McGill University Christian Schulz-​Quach, MD, MSc, MA
Montréal, QC, Canada Assistant Professor
Department of Psychiatry
Barry Rosenfeld, PhD
University of Toronto
Professor
Toronto, ON, Canada
Chairman
Department of Psychology Lisa A. Schwartz, PhD
Fordham University Associate Professor
Consultant Psychologist Department of Pediatrics/​Oncology
Psychiatry Service The Children’s Hospital of Philadelphia
Department of Psychiatry and Behavioral Sciences Philadelphia, PA, USA
Memorial Sloan Kettering Cancer Center Michael Schwartz, MD, FACS
New York, NY, USA Associate Professor
Andrew J. Roth, MD Smith Institute for Urology
Attending Psychiatrist Northwell Health
Psychiatry Service New Hyde Park, NY, USA
Department of Psychiatry and Behavioral Sciences Peter A. Selwyn, MD, MPH
Memorial Sloan Kettering Cancer Center Professor and Chair
Professor of Clinical Psychiatry Department of Family and Social Medicine
Weill Cornell Medical College Director, Palliative Care Program
New York, NY, USA Montefiore Medical Center
Julia Ruark, MD, MPH Albert Einstein College of Medicine
Attending Psychiatrist The Bronx, NY, USA
Department of Psychosocial Oncology Kelly M. Shaffer, PhD
Seattle Cancer Care Alliance Assistant Professor
Seattle, WA, USA Center for Behavioral Health and Technology, Department of Psychiatry and
Elizabeth Ryan, PhD, ABPP-​CN Neurobehavioral Sciences
Associate Attending Neuropsychologist University of Virginia School of Medicine
Psychiatry Service Charlottesville, VA, USA
Department of Psychiatry and Behavioral Sciences Mehak Sharma, MD
Memorial Sloan Kettering Cancer Center Assistant Attending Psychiatrist
New York, NY, USA Psychiatry Service
Adam Rzetelny, PhD Department of Psychiatry and Behavioral Sciences
Senior Medical Science Liaison Memorial Sloan Kettering Cancer Center
Department of Medical Affairs New York, NY, USA
Collegium Pharmaceuticals
Maplewood, NJ, USA
Contributors xxv

Louise Sharpe, BA(Hons), MPsychol, PhD Manuel Trachsel, MD, PhD

Professor of Clinical Psychology Head Clinical Ethicist
Department of Psychology Clinical Ethics Unit
The University of Sydney University Hospital of Basel/​University of Zurich
Camperdown, NSW, Australia Zürich, ZH, Switzerland
Michael Sharpe, MA, MD Lara Traeger, PhD
Professor of Psychological Medicine Assistant Professor
Department of Psychiatry Department of Psychiatry
University of Oxford Massachusetts General Hospital/​Harvard Medical School
Oxford, UK Boston, MA, USA
Vani N. Simmons, PhD Kelly M. Trevino, PhD
Senior Member Associate Attending Psychologist
Department of Health Outcomes and Behavior Psychiatry Service
Moffitt Cancer Center Department of Psychiatry and Behavioral Sciences
Tampa, FL, USA Memorial Sloan Kettering Cancer Center
Allan B. Smith, PhD New York, NY, USA
Co-​Deputy Director (Policy and Practice) Jane Turner, MBBS, PhD, FRANZCP
Centre for Oncology Education and Research Translation (CONCERT) Professor
Ingham Institute for Applied Medical Research Department of Psychiatry
Liverpool, NSW, Australia The University of Queensland
Jennifer Sotsky, MD, MS Brisbane, Australia
Clinical Fellow Lisa Tussing-​Humphreys, PhD, MS, RD
Department of Psychiatry Associate Professor
New York State Psychiatric Institute Department of Medicine Co-​leader, Cancer Prevention and Control Program,
New York, NY, USA Cancer Center
Nadia van der Spek, PhD University of Illinois
Assistant Professor Chicago, IL, USA
Licensed Mental Health Care Psychologist Susan T. Vadaparampil, PhD, MPH
Department of Clinical Psychology Associate Center Director, Community Outreach, Engagement, and Equity
Vrije Universiteit Amsterdam Department of Health Outcomes and Behavior
Amsterdam, The Netherlands Moffitt Cancer Center
Kevin Stein, PhD, FAPOS Tampa, FL, USA
Associate Professor (Adjunct) Annalyn Valdez-​Dadia, DrPH, MPH
Department of Behavioral Sciences and Health Education Assistant Professor
Rollins School of Public Health Department of Human Services
Snellville, GA, USA California State University, Dominguez Hills
Chelsea R. Stone, MSc Carson, CA, USA
Research Associate Alan D. Valentine, MD
Department of Cancer Epidemiology and Prevention Research Professor and Chair
Alberta Health Services Department of Psychiatry
Calgary, AB, Canada MD Anderson Cancer Center
Sarah J. Tarquini, PhD The University of Texas
Senior Psychologist Houston, TX, USA
Department of Psychosocial Oncology and Palliative Care Sally W. Vernon, MA, PhD
Dana-​Farber Boston Children’s Cancer and Blood Disorders Center Professor
Boston, MA, USA Department of Health Promotion and Behavioral Science
Ovidiu Tatar, MD, MSc University of Texas School of Public Health
Research Associate Houston, TX, USA
Psychosocial Oncology Lady Davis Institute for Medical Research Froukje de Vries, MD, PhD
Jewish General Hospital Research Center-​Centre Hospitalier Psychiatrist
de l'Université de Montréal (CRCHUM) Department of Supportive Care
Montréal, QC, USA Princess Margaret Cancer Centre, University Health Network
Kim Thiboldeaux, BA Communications Toronto, ON, Canada
CEO Claire E. Wakefield, BPsych(Hons), MPH, PhD
Cancer Support Community Professor
Washington, DC, USA School of Women’s and Children’s Health and Kids Cancer Centre
Teresa H. Thomas, PhD, RN UNSW Sydney and Sydney Children’s Hospital
Assistant Professor North Willoughby, NSW, Australia
School of Nursing Leah E. Walsh, MS
University of Pittsburgh Doctoral Student
Pittsburgh, PA, USA Department of Psychology
Amanda L. Thompson, PhD Fordham University
Chief, Pediatric Psychology The Bronx, NY, USA
Department of Life with Cancer
Inova Schar Cancer Institute
Fairfax, VA, USA
xxvi Contributors

Linda D. L. Wang, PhD Joseph T. Wu, PhD, BS

Associate Professor Professor
Department of Clinical Medicine School of Public Health
Medical College of Yangzhou University The University of Hong Kong
Yangzhou, Jiangsu, China Hong Kong, China
Maggie Watson, BSc, Dip Clin Psych, PhD Robert Zachariae, DMSc
Honorary Professor Professor
Research Department of Clinical, Educational and Health Psychology Unit for Psycho-​oncology and Health Psychology
University College London Aarhus University
Institute of Cancer Research Aarhus, Denmark
London, UK Talia I. Zaider, PhD
Amanda Watsula-​Morley, MA Assistant Attending Psychologist
Clinical Research Supervisor Psychiatry Service
Department of Psychiatry and Behavioral Sciences Department of Psychiatry and Behavioral Sciences
Memorial Sloan Kettering Cancer Center Memorial Sloan Kettering Cancer Center
New York, NY, USA New York, NY, USA
Jason A. Webb, MD, FAPA, FAAHPM Alexandra K. Zaleta, PhD
Director of Education, Duke Center for Palliative Care Associate Professor Senior Director of Research
Department of Medicine, Department of Psychiatry and Behavioral Sciences Department of Research and Training Institute
Duke University Cancer Support Community
Durham, NC, USA Philadelphia, PA, USA
Lori Wiener, PhD, DCSW, FAPOS Bradley J. Zebrack, MSW, MPH, PhD
Co-​Director, Behavioral Health Care, Professor
Director, Psychosocial Support and Research Program School of Social Work
Department of Pediatric Oncology Branch, University of Michigan
National Cancer Institute, Center for Cancer Research Ann Arbor, MI, USA
National Institutes of Health
Bethesda, MD, USA
Irene O. L. Wong, BSc, MPhil, MMedSci, PhD
Scientific Officer
School of Public Health
The University of Hong Kong
Hong Kong, China
Introduction
Our Past, Our Future—New Frontiers in Psycho-​Oncology
William S. Breitbart (Senior Editor)

Introduction psycho-​ oncology. Interestingly, Jimmie hated being called the

“mother” of psycho-​oncology. It particularly irked her when, as she
This textbook, Psycho-​Oncology, 4th edition, is the first edition of this got older, this term changed to “grandmother” of psycho-​oncology.
series of textbooks, which have defined the field of psycho-​oncology, Jimmie much preferred these titles/​roles to be reserved for her per-
to be edited without Jimmie C. Holland as the senior editor. Jimmie’s sonal life—​her family, her beloved children and grandchildren. But
imprint on these textbooks and on our international field has resulted after all, she was a “Cicely Saunders–​type” figure in a new movement
in these textbooks often being referred to as the “Holland Textbook within oncology, and so she was revered and mythologized in ways
of Psycho-​Oncology”—​that is, when it isn’t, perhaps somewhat sacri- that did not make her comfortable. As many who knew Jimmie will
legiously, being referred to as the “Bible of Psycho-​Oncology.” Hence, attest, she was in fact somewhat shy and quite humble, quick to give
those of us who have taken on the both sacred and significant responsi- credit to others, and eager to accelerate the career trajectories of the
bility of editing this 4th edition of Psycho-​Oncology have done so with a next generations of clinicians, scientists, and leaders of our field. That
sense of both sadness and honor. The field of psycho-​oncology is truly isn’t to imply that she didn’t have very strong opinions or have envi-
interdisciplinary and international, and so it is fitting that the editors able political skills, but she clearly used those skills for the benefit of
and contributors to this 4th edition are indeed truly international and patients, the field, and the movement. Jimmie and I would often sit
represent multiple disciplines. As senior editor, I have been blessed to in her office at the end of the day and discuss just about everything
have the magnificent talents of the following luminaries in our field one can imagine related to work, projects, our field, and politics (and
as associate editors: Phyllis N. Butow, BA(Hons), DipEd, MClinPsych, some gossip). There was nothing off limits. Interestingly, we did fre-
MPH, PhD, of the University of Sydney; Paul B. Jacobsen, PhD, of the quently talk about the origins of psycho-​oncology and individuals
U.S. National Cancer Institute; Wendy W. T. Lam, RN, PhD, FFPH, she felt never quite received enough recognition for their roles in the
of the University of Hong Kong; Mark Lazenby, APRN, PhD, of the creation of our field. That is, in part, why she urged the creation of
University of Connecticut School of Nursing; and Matthew J. Loscalzo, the IPOS Arthur Sutherland Award. Jimmie always felt that she had
MSW, LCSW, FAPOS, of the City of Hope. Their contributions to the received too much credit for founding the field of psycho-​oncology
quality of this textbook will be quite evident to the reader. Each of the and was eager for there to be recognition of such pioneers in our
editors of this textbook has had a direct and often life-​changing expe- field as Margit Von Kerekjarto, Robert Zitoun, Hiroomi Kawano,
rience through a long-​standing relationship with Jimmie Holland, and Steven Greer, Lea Baider, Peter Maguire, Bernard Fox, Juan Ignacio
our dedication to preserving her legacy is on every page of this text. Romero, Avery Weissman, Edwin Cassem, Noemi Fisman, Maria
I do want to take a moment to personally thank Andrea Knobloch, Margarida Carvalho, Morton Bard, and Arthur Sutherland himself.
our editor at Oxford University Press, and her team; the personal as- One early pioneer has remained quite obscure and
sistants of many of the editors and contributors; and most significantly underrecognized for over 50 years, and Jimmie and I became quite
Laurie Schulman, who served as managing editor of this textbook fascinated with this figure. I became interested because he, like my
and dedicated more than a year of time, energy, and devotion to as- parents, was a Holocaust survivor. Jimmie, I believe, became fascin-
sisting me in seeing this project through—​even through the interrup- ated because he was also someone who had overcome severe phys-
tions of the coronavirus pandemic. Lastly, our deep appreciation goes ical disabilities (reminding Jimmie of her early days working with
to the International Psycho-​Oncology Society (IPOS), the American polio patients). Loma Feigenberg was a physician at the Karolinska
Psychosocial Oncology Society (APOS), and the several hundred au- Institute in Stockholm. In the 1950s, as an oncologist and radiother-
thors who contributed more than 100 chapters to this textbook. apist, he noted the lack of attention in addressing the psychological
responses of patients with advanced cancer. He later studied psy-
chiatry and began to work with cancer patients at the Karolinska.
Our Past He made what he called a “friendship contract” with them in which
he agreed to “confidentiality” of the content of their “sessions” and
Jimmie C. Holland, or “Jimmie,” as the world of psycho-​oncology made a commitment to ongoing care and support during their cancer
knew her, is often credited as being the founder or “mother” of treatment. His book, Terminal Care: A Method for Psychological Care
2 Psycho-Oncology

of Dying Patients, is a landmark text.1 Feigenberg did finally receive expertise. We were particularly interested in two aspects of the
the Distinguished Life Service Award from the IPOS in 1987. He purpose of the Psycho-​Oncology textbook’s purpose: (1) to serve
also founded the International Work Group for Death, Dying and as the source textbook that provided the broadest and most mul-
Bereavement (IWG), an early beginning of thanatology. tidisciplinary and essential science and practice of the field of
However, Dr. Holland’s efforts over the last 43 years, since be- psycho-​oncology, and (2) to bring to our field the newest and latest
coming the founding chief of the Psychiatry Service at Memorial innovations and cutting-​edge research and clinical practice that
Sloan Kettering Cancer Center, have indeed brought her well-​ would equip our readers with the knowledge and resources to be
deserved recognition as the founder and past leader of the field of knowledgeable and to participate in the “new frontiers of psycho-​
psycho-​oncology. Having founded the IPOS in 1984 and the APOS in oncology.” We feel we have accomplished this delicate but critical
1986, Dr. Holland went on to edit the first major textbooks of psycho-​ balance in the 4th edition of Psycho-​Oncology.
oncology for our field. This textbook, Psycho-​Oncology, 4th edition, We’ve maintained many of the basic but critical aspects of pre-
was preceded by four major textbooks that defined our field. In 1989, vention, screening, assessment, and management of basic common
Dr. Holland edited the Handbook of Psychooncology: Psychological psychosocial and psychiatric issues in psycho-​oncology, including
Care of the Patient with Cancer, the first major textbook in our field.2 cancer site–​specific psychosocial issues and management. As much
This landmark book (coedited with Julia Rowland, PhD) established as possible, these cancer site–​specific chapters also include some
our “new” field and virtually named the field “psycho-​oncology.” The basic, updated oncological diagnostic and treatment-​related infor-
follow-​up textbook Psycho-​Oncology was published in 1998 and rep- mation that is vital for clinicians and clinical researchers in our field.
resented the most comprehensive, multidisciplinary, and interna- There are, however, a number of new sections that represent new
tional encyclopedia of a field entering its adolescence.3 The year 2010 developments in basic psycho-​oncology science, breakthroughs in
saw the publication of the 2nd edition,4 followed by the 3rd edition5 health care delivery, growth in treating special cancer populations,
in 2015, both published by Oxford University Press in collaboration and innovative and novel evidence-​based interventions that are
with the IPOS and APOS. The field of psycho-​oncology was now changing the landscape of treatment, and a growing international
mature, rich, and filled with talented, creative, and innovative clin- perspective that our field has developed over recent years.
icians, scientists, advocates, and global leaders like Maggie Watson, Allow me to briefly highlight some of the updates and new sections
Luigi Grassi, Uwe Koch, David Kissane, Christoffer Johansen, Luzia in the 4th edition of Psycho-​Oncology that are designed to prepare
Travado, Barry Bultz, Maria Die Trill, Gary Rodin, Cristina Bolund, psycho-​oncologists for the “new frontiers of psycho-​oncology”:
Bill Redd, Anja Mehnert, Francisco Gil, David Spiegel, Joan Bloom,
1. Evidence-​Based Interventions: We have dramatically expanded
Harvey Chochinov, Barbara Andersen, Jamie Ostroff, Phyllis Butow,
this section of the textbook and now include a variety of inno-
Paul Jacobsen, Richard Fielding, Matt Loscalzo, Leslie Fallowfield,
vative novel interventions with a significant evidence base for
Pierre Gagnon, Jeff Dunn, Mitch Golant, Mary Jane Esplen, Sharon
efficacy. We’ve divided the interventions into models of care
Manne, Jane Turner, David Cella, Elisabeth Andritsch, Pat Fobair,
delivery and phases of illness. Models of Care Delivery now in-
Irma Verdonck-​de Leeuw, Michael Antoni, James Zabora, and nu-
cludes the following:
merous others (apologies to anyone who deserved mention and was
(a) Collaborative and Integrated Models of Psychosocial
omitted unintentionally; noninclusion in this list means you’re not
Oncology Care, Community-​ Based Care, and
an old-​timer and are part of the new wave, the vital leaders of the
Implementation Science’s Role in Care Delivery
future of our field).
With the publication of this textbook, Psycho-​Oncology, 4th edi- (b) Family and Couples Interventions
tion, we take this moment to both look to our past and start to ex- (c) Interventions at various stages of illness including Active
amine our future as a field. We have a rich legacy given to us by so Treatment, Advanced Disease, and Survivorship, as well
many of the pioneers of psycho-​oncology mentioned earlier. In fact, as novel interventions including Cognitive-​ Behavioral
this textbook is dedicated to the memory of Jimmie C. Holland and Interventions, Mindfulness-​Based Interventions, Acceptance
we honor her and all the past editors and contributors to the prior and Commitment Therapy, Interpersonal Therapy,
editions of this text by moving forward with the creation of what Supportive-​ Expressive Psychotherapy, and Meaning-​
we hope readers will someday view as a milestone textbook itself. Centered Psychotherapy for advanced cancer patients, for
Of note, two former associate editors of several of the prior editions bereavement, survivors, and for caregivers, in addition to
of this series of textbooks died in 2019 as this 4th edition was being CALM Therapy, Dignity Therapy, Emotionally Focused
prepared. We are indebted to and honor the contributions and lives Therapy, Metacognitive Approaches, Integrative Oncology
of Ruth McCorkle and Marguerite Lederberg—​ two remarkable Interventions, and Physical Activity Interventions. We had
women who were cherished by so many of us, worldwide. Ruth was hoped to include Light Therapy, but that was not possible.
an editor of several editions of the textbook and so we also dedicate 2. Digital Health Interventions: We have an expanded section
this textbook in her honor as well as in Jimmie’s. on e-​health intervention delivery, which ranges from preven-
tion, smoking cessation, and psychosocial distress to Physical
Symptom Control.
Our Future 3. Biobehavioral Psycho-​Oncology: We have included the first
ever section on the science of stress and cancer risk and pro-
We, the editors of this 4th edition of Psycho-​Oncology, undertook gression. We have wonderful contributions from Mike Antoni
a careful examination of the content of the 3rd edition of Psycho-​ and coauthors of Stress Processes and Cancer Progression;
Oncology, as well as the expert authors who contributed their Depression, Inflammation, and Cancer from Andrew Miller and
Our Past, Our Future 3

coauthors; and Biobehavioral Psycho-​Oncology Interventions counseling presented by this revolution in medical oncology.
from Michael Hoyt and Frank Penedo. This somewhat contro- This section has chapters on genetic testing in breast and
versial area of psycho-​oncology research has now reached a ovarian cancer, testing in hereditary cancers, genomic testing
level of maturity and there are evidence-​based findings of which for targeted therapies, and psychosocial issues related to large-​
all psycho-​oncologists must be aware. scale liquid biopsy screening for mutations in normal and at-​
4. Geriatric Oncology: This is a growing field in psycho-​oncology. risk populations. Mary Jane Esplen, Susan Peterson, Megan
This section includes chapters on screening, assessment, inter- Best, Jada Hamilton, and their coauthors have contributed out-
ventions, and communications issues specific to managing standing chapters.
older cancer patients. Christian Nelson, Andrew Roth, Kelly 11. Screening and Assessment in Psychosocial Oncology: We’ve
Trevino, Patricia Parker, Beatriz Korc-​Grodzicki, and Yesne experienced a revolution in screening and brief assessments
Alici were the primary contributors to this section. Their con- of patients at risk for distress, anxiety, depression, delirium
tributions acknowledge the pioneering work of our late friend and cognitive disorders, suicidal ideation, and uncontrolled
and colleague Arti Hurria. symptoms. This section addresses many of these issues. Paul
5. Pediatric Psycho-​Oncology: For the very first time, Pediatric Jacobsen, Kristine Donovan, Alex Mitchell, Tim Ahles, James
Psycho-​Oncology is fully included and represented in the Root, Bill Breitbart, Yesne Alici, and their colleagues have con-
Psycho-​Oncology series of textbooks. This section has chap- tributed outstanding chapters.
ters on pediatric psycho-​oncology screening and assessment, 12. Building Supportive Care Teams; Psycho-​Oncology in Health
management of common psychiatric disorders, evidence-​ Policy: These sections are expanded and have a broad interna-
based interventions in pediatric psycho-​oncology, and ad- tional perspective.
olescent and young adults with cancer. The contributors to
these sections include the leaders of the field—​Anne Kazak,
Maryland Pao, Julia Kearney, Lori Wiener, Anna Muriel, and Informed by Our Past, Inspired to Create a
Bradley Zebrack. Better Future
6. Survivorship: This section has been expanded and has inter-
esting new information on approaches to Fear of Recurrence in We have a great legacy. That is the gift our field has received from its
Cancer Survivors. pioneers. We human beings engage in what is termed “cumulative
7. Palliative Care and Advanced Planning: These chapters focus learning.” We build upon the wisdom and knowledge chronicled by
on the need to focus on treatment decision making; discus- those who came before us. Einstein’s work on gravity could not have
sion of advance care planning and care goals at the time of taken place without building upon our knowledge of the chronicled
diagnosis—​early in the course of life-​threatening cancer; and work of Newton. We are building upon the knowledge accumulated
prognostic awareness and the role of the psycho-​oncologist in and documented by psycho-​oncologists who dedicated their work
palliative care. The interface of psycho-​oncology and palliative to establishing and growing a base of research and clinical innova-
care is a critically important one that needs to be navigated with tion over the last 50 years. It is our responsibility to contribute to this
a sense of collaboration and integration. Michael Diefenbach, “cumulative” knowledge base and move our field forward to better
Stefanie Mooney, Scott Irwin, Barry Rosenfeld, and Allison “care for the whole person with cancer.” Our hope is that you, the
Applebaum and their coauthors have contributed outstanding readers of the 4th edition of Psycho-​Oncology, feel we have made a
chapters. valuable contribution to fulfilling the solemn responsibility we have
8. Diversities in the Experience of Cancer: This expanded new inherited: to create a better future.
section addresses the important issues of cancer and cul-
William S. Breitbart, MD, FAPOS
ture; cancer disparities; access to care and food; financial and
Senior Editor
housing insecurities; cancer and sexual minorities; and the ex-
Psycho-​Oncology, 4th edition
perience of cancer as an immigrant. The contributors to this
section include leaders in these areas such as Marjorie Kagawa-​
Singer, Francesca Gany, Victoria Blinder, Jennifer Leng, and REFERENCES
Charles Kamen. 1. Feigenberg L. Terminal care: Friendship contracts with dying
9. Behavioral and Psychological Factors in Cancer Risk; cancer patients. New York, Brunner/​Mazel, 1980.
Screening for Cancer in Normal and At-​Risk Populations: 2. Holland JC, Rowland J, Eds: Handbook of Psychooncology.
These sections have been expanded and include a broad inter- New York, Oxford University Press, 1989.
national perspective. Contributors include many luminaries 3. Holland JC, Breitbart WS, Jacobsen PB, Lederberg MS, Loscalzo
such as Christoffer Johansen, Jamie Ostroff, Richard Fielding, M, Massie MJ, McCorkle R, Eds: Psycholo-​Oncology. New York,
Jennifer Hay, Gabriel Leung, and many others. Oxford University Press, 1998.
10. Screening and Testing for Germ Line and Somatic Mutations: 4. Holland JC, Breitbart WS, Jacobsen PB, Lederberg MS, Loscalzo
M, McCorkle R, Eds: Psycho-​Oncology 2nd Edition. New York,
With the advent of precision oncology and therapies targeted
Oxford University Press, 2010.
at actionable tumor mutations, psycho-​oncologists have had
5. Holland JC, Breitbart WS, Butow PN, Jacobsen PB, Lederberg
to learn a great deal about genetics, and now we have begun
MS, Loscalzo M, McCorkle R, Eds: Psycho-​Oncology 3rd Edition.
to explore the various psychosocial sequelae and the need for New York, Oxford University Press, 2015.
SECTION I
Behavioral and Psychological
Factors in Cancer Risk and
Prevention
Paul B. Jacobsen (Section Editor)

1 Tobacco Use and Cessation 7 4 Sun Exposure and Cancer Risk 30

Thomas H. Brandon, Vani N. Simmons, Úrsula Martínez, and Suzanne J. Dobbinson, Afaf Girgis, Bruce K. Armstrong,
Patricia Calixte-Civil and Anne E. Cust
2 Diet and Cancer 13 5 Psychosocial Factors 36
Marian L. Fitzgibbon, Lisa Tussing-Humphreys, Angela Kong, Anika von Heymann and Christoffer Johansen
and Alexis Bains
6 Viral Cancers and Behavior 43
3 Physical Activity, Sedentary Behavior, Susan T. Vadaparampil, Lindsay N. Fuzzell,
and Cancer 21 Shannon M. Christy, Monica L. Kasting, Julie Rathwell,
Christine M. Friedenreich, Chelsea R. Stone, and Anna E. Coghill
and Jessica McNeil
1
Tobacco Use and Cessation
Thomas H. Brandon, Vani N. Simmons, Úrsula Martínez, and Patricia Calixte-​Civil

Tobacco and Cancer to smoking cessation interventions, increasing tobacco taxes, or

introducing public warnings about the dangers of tobacco use.
Each year over 7 million people die worldwide due to tobacco use.1 Although these actions have led to a global reduction in tobacco use
Smoking is responsible for about 22% of all cancer deaths globally. in most developed countries, these nations still account for half of all
It accounts for over two-​thirds of all lung cancer mortalities and female daily smokers and roughly 75% of male daily smokers. Efforts
contributes significantly to mortality rates for oral cancer, as well as to reduce tobacco use have been successful in developed countries,
bladder, stomach, liver, pancreas, kidney, cervical, and colorectal can- and they should be bolstered in developing countries (i.e., coun-
cers.2 In addition to cancer, smoking contributes to coronary heart di- tries with historically lower education, per capita income, and life
sease, chronic obstructive pulmonary disease, cardiovascular disease, expectancy). Developing countries have shown moderate smoking
stroke, and peptic ulcers. Indeed, about 20% of all deaths in the United prevalence across time, but many of these nations are showing in-
States can be attributed to smoking. From the individual perspective, creases in the prevalence of smoking and smoking-​related mortality
a given smoker has about a 50% chance of dying from smoking, with that are commensurate with increases in income, decreases in the
the average smoker living 10 years less than a nonsmoker.3 Although cost of tobacco, heavier marketing from the tobacco industry, and
there are risks associated with noncombustible tobacco use (e.g., chew, limited tobacco-​related public health policies. As such, developing
snuff), this chapter focuses on combustible tobacco use (i.e., smoking) countries are vulnerable to assuming the burden of the tobacco
because of its much higher prevalence and relative risk. Nevertheless, epidemic.1 Moreover, tobacco use burden is disproportionately af-
patients should be advised to cease all forms of tobacco use. fecting certain segments of the population worldwide. For example,
Smoking cessation is associated with decreased mortality and tobacco use is rapidly increasing among youth, especially females,
morbidity from cancer and other diseases. Stopping smoking at age in developing countries, and it is highly prevalent among individ-
30 restores nine years of life expectancy, whereas stopping at age 60 uals with low income across nations, regardless of per capita gross
still restores an expected three years of life, compared to continuing national income.5
to smoke.3 Thus, great potential for cancer prevention lies with long-​ In the U.S., since the seminal 1964 U.S. Surgeon General’s report,
term cessation of smoking. In this chapter, we begin by noting the the prevalence of smoking among adults has dramatically declined
changing demographic profile of current smokers. We then review from nearly half of adults to less than one in five.6 The current dem-
the evidence-​based treatments for tobacco use and dependence, em- ographic profile of smokers is markedly different than decades ago
phasizing primarily qualitative and meta-​analytic reviews. We draw because the reduction in smoking prevalence has not been con-
upon the 2008 update of the U.S. Public Health Service’s Clinical sistent across demographic groups. These differences in prevalence
Practice Guideline, Treating Tobacco Use and Dependence,4 which is of tobacco use are associated with differential burdens of tobacco-​
based on a review of 8,700 research articles, with treatment recom- related morbidity and mortality. In particular, a substantial body
mendations derived from meta-​analyses of most treatment modal- of evidence demonstrates that lower educational attainment, being
ities. We then discuss special issues of relevance for treating cancer below the poverty level, identifying as American Indian/​Alaska
patients. New to this update is a discussion of electronic cigarettes Native, living in the Midwest or South, working in a blue-​collar or
(e-​cigarettes), the use of which has grown exponentially over the service industry, having active military or veteran status, having a
past decade, including among cancer patients. disability, having a severe mental illness, and not having health in-
surance are associated with higher prevalence of smoking in the U.S.
There are also more recent changes in the demographics of to-
Evolving Landscape of Tobacco and Nicotine Use bacco users that coincide with shifts in the racial/​ethnic composition
of the U.S. and/​or more inclusive data collection. That is, subgroups
Changing Demographics of Tobacco Users who identify as more than one race/​ethnicity, as sexual or gender
Several countries have implemented strategies toward reducing minorities, or as immigrants report greater tobacco use. Regarding
tobacco burden, such as monitoring tobacco use, offering access race/​ethnicity, although Hispanics and non-​Hispanic Asians have
8 SECTION I Factors in Cancer Risk and Prevention

among the lowest smoking prevalence by race/​ethnicity (12.7% and these medications have been found to approximately double the odds
8%, respectively), there is wide variation in smoking behavior within of long-​term abstinence (with one, varenicline, tripling the odds),
the subgroups and across gender. Among foreign-​born men living and the Clinical Practice Guideline issued by the U.S. Department of
in the U.S., 24.8% of Mexicans, 47.7% of Filipinos, and 52.7% of Health and Human Services recommends that pharmacotherapy be
Chinese people reported being current smokers, which is of partic- routinely offered to smokers attempting to quit.4
ular relevance to healthcare in the United States given that Mexico,
the Philippines, and China represent three of the top five countries Nicotine Replacement Therapies
with the largest populations of foreign-​born individuals in the U.S. Nicotine replacement therapy (NRT) aids smoking cessation by
In 2010 alone, 29.3% of all immigrants living in the U.S. were from partially replacing plasma nicotine levels, thereby reducing symp-
Mexico. Thus, the distribution of tobacco use and its consequent toms of nicotine withdrawal (e.g., craving, depression, irritability,
health and economic burdens are unequal and shifting, requiring difficulty concentrating) and possibly reducing the reinforcement
attention by both researchers and clinicians. derived from any cigarettes smoked. Five types of NRT have FDA
approval: chewing gum, transdermal patch, intranasal spray, in-
The Emergence of Electronic Cigarettes haler device, and lozenge. In general, NRT is used during the first
E-​cigarette use has grown dramatically in the last 10 years. E-​ 8–​12 weeks of abstinence, when nicotine withdrawal symptoms are
cigarettes include a battery and heating element that aerosolizes a greatest. Of the five NRT delivery methods, the nicotine nasal spray
liquid that typically contains nicotine, flavorants, propylene glycol, reaches its peak concentration most rapidly, whereas the trans-
and vegetable glycerin. Since their introduction, the available prod- dermal patch provides the slowest, but most consistent, serum nico-
ucts have expanded and evolved in terms of their ease of use, their tine levels over the course of a day.
sophistication, and their efficiency of nicotine delivery. The newest Meta-​analyses indicate roughly equivalent efficacies for the five
devices deliver a nicotine dose similar to a combustible cigarette, NRT products, with odds ratios ranging from 1.5 (for nicotine gum)
while also simulating the sensorimotor aspects of smoking (e.g., to 2.3 (for nasal spray) compared to placebo.4 Estimated six-​month
hand and arm movements, puffing and inhalation behavior, and abstinence rates are approximately 20%–​25%. Each product is as-
visible exhalation). Theoretically, these similarities should ease the sociated with specific contraindications and cautions, primarily re-
transition from combustible cigarettes to e-​cigarettes. Although lated to its particular mode of drug delivery. Because NRT delivers
there have been regulatory barriers to conducting randomized con- nicotine without the harmful byproducts of smoked tobacco, it is
trolled trials of e-​cigarettes for smoking cessation, evidence of their considered a far safer alternative to smoking. The safety of NRT
efficacy is now emerging.7 However, e-​cigarettes have generated a during pregnancy has not been established.
magnitude of controversy and division never before seen in the to-
bacco control and research fields. The current scientific consensus Bupropion SR (Zyban®)
is that e-​cigarettes are substantially less harmful than combustible Bupropion was the first non-​nicotine medication to be approved
cigarettes,8 and therefore complete switching from smoking to by the FDA for treating tobacco dependence. Also marketed as an
“vaping” represents significant harm reduction at the individual and atypical antidepressant (Wellbutrin®), bupropion doubles tobacco
population levels. However, there is growing concern about the re- abstinence rates compared to placebo, with an average odds ratio
cent uptake of vaping by youth and the unknown long-​term health of 2.0, and an abstinence rate of approximately 24%.4 It attenu-
outcomes of this behavior. The primary public health challenge re- ates nicotine withdrawal and cigarette cravings, and can reduce
lated to tobacco use is to develop policy that promotes switching by postcessation weight gain. Bupropion’s mechanism of action is not
current smokers while minimizing uptake of vaping by youth who fully understood, but it appears to inhibit the neuronal reuptake
would not have otherwise used nicotine products. of dopamine and norepinephrine—​key neurotransmitters in the
maintenance of nicotine dependence. It may also have antagonistic
effects on nicotinic receptors, attenuating perceived satisfaction
Treatment of Tobacco Use and Dependence from smoking.
To reach steady-​state blood levels before quitting smoking, the
Tobacco dependence has multiple motivational influences within smoker should begin using bupropion SR one week before the
and across individual smokers.9 Among these are physical depend- target quit date. Contraindications include a history of seizure dis-
ence on nicotine, operant and classical conditioning processes, en- orders or factors known to increase the risk of seizures (e.g., bu-
vironmental and social factors, cognitive expectancies about the limia or anorexia nervosa, serious head trauma, alcoholism) and
benefits of smoking, and desire for weight control. Given the com- concomitant use of monoamine oxidase (MAO) inhibitors. Because
plexity of the factors influencing smoking, it is not surprising that of postmarketing reports of neuropsychiatric adverse events, in-
single-​treatment approaches have limited success, with the best cluding suicidality, the FDA required “black box” warnings on
long-​term outcomes obtained from multimodal treatments. In this both bupropion and varenicline (see later) with respect to possible
section, we review pharmacological interventions, followed by so- neuropsychiatric adverse events, including depression, psychosis,
cial/​behavioral interventions, broadly defined, and finally discuss aggression, agitation, and anxiety, as well as suicidal ideation or be-
combination treatments. havior. Although the warning remains, the black box was rescinded
in 2016 following additional research that failed to find elevated
Pharmacotherapy neuropsychiatric events for varenicline or bupropion compared to
Currently, there are seven pharmacotherapies approved by the U.S. NRT or placebo. The safety of bupropion during pregnancy has not
Food and Drug Administration (FDA) for smoking cessation. All of been established.
CHAPTER 1 Tobacco Use and Cessation 9

Varenicline (Chantix®) more personal and intensive help than self-​help materials, while also
Varenicline was the last pharmacotherapy approved for treating having greater potential reach than face-​to-​face counseling. Meta-​
nicotine dependence. It is an orally administered partial agonist of analyses show that quitlines are effective, with overall odds ratios of
α4β2 nicotinic acetylcholine receptors (nAChRs). Varenicline ap- 1.4–​1.6 compared to control conditions, which translates into differ-
pears to reduce nicotine cravings and withdrawal symptoms, and ential long-​term abstinence rates of at least 3%–​5%.4
its agonistic properties appear to attenuate the reinforcing effects Brief Interventions
of smoking, including perceived satisfaction.10 Similar to bupro-
pion, varenicline use should be initiated one week before the target Healthcare providers have the opportunity to deliver relatively brief
quit date. Evidence suggests that it has outperformed bupropion in face-​to-​face interventions. The U.S. Public Health Service (PHS)
head-​to-​head studies and is the most effective of the smoking cessa- Clinical Practice Guideline describes an effective brief smoking ces-
tion medications, with an average odds ratio of 3.1, producing 33% sation intervention model most commonly referred to as the “5’A’s.”4
abstinence.4 The five key steps include (1) “Asking” every patient about tobacco
The main adverse effect of varenicline is mild to moderate nausea. use at repeated visits, (2) “Advising” every tobacco user to quit by
However, as with bupropion, warnings of neuropsychiatric adverse providing clear and personalized advice to quit, (3) “Assessing” the
events are also included in labeling. In addition, there is some evi- willingness of patients to quit, (4) “Assisting” patients with quitting,
dence that varenicline may increase the risk of major cardiovascular and (5) “Arranging” follow-​up cessation support, ideally within a
events. Varenicline is not approved for use with pregnant women. few weeks of the quit attempt. Meta-​analyses have indicated that
physician advice alone increases abstinence rates by approximately
Combination Pharmacotherapies 2.3%–​2.5%.4 Because 70% of smokers visit their physician each year,
Recent research has tested the efficacy of combining different forms the potential cumulative effect of even this small effect is sizable.
of pharmacotherapy. The general model has been to combine a long-​ Moreover, there is a dose–​response relationship between contact time
acting, relatively stable medication, such as the nicotine patch, with and abstinence outcomes, with minimal counseling (< 3 minutes)
a shorter-​acting medication that can be used ad libitum. In this yielding 13.4% abstinence, low-​intensity counseling (3–​10 minutes)
manner, both tonic and phasic nicotine cravings and withdrawal yielding 16.0% abstinence, and higher-​intensity counseling (> 10
symptoms can be addressed. The combination of nicotine patch with minutes) yielding 22.1% abstinence. Abstinence rates also increase
gum, nasal spray, or inhaler has evidence of significant efficacy, as with the number of counseling meetings and/​or the number of cli-
does the combination of the patch and bupropion SR.4 nician types delivering the cessation messages.4 Alternative models
that reduce provider burden include Ask-​Advise-​Refer (AAR) and
Social/​Behavioral Treatments Ask-​Advise-​Connect (AAC). In both abbreviated models, patients
The nonpharmacological therapies described in this section span a are asked about their smoking and are delivered brief advice to quit.
wide range of intensity and duration, from minimal self-​help inter- However, in the AAR model, patients are then referred to evidence-​
ventions to intensive individual counseling. Clinicians should be based cessation programs for assistance in quitting (e.g., a quitline).
aware of the availability of these options and should be willing to Designed to overcome patient barriers that exist with use of a pas-
refer patients for services that they are unable to provide themselves. sive referral model, the AAC model directly connects patients to the
smoking cessation resource via an automated connection system
Self-​help within the electronic health record (EHR). The AAC method has
Self-​help refers to materials that can be provided to smokers, such demonstrated greater impact over the AAR model with respect to a
as pamphlets, booklets, or audiovisual media. Their primary ad- higher proportion of smokers enrolling in treatment.12
vantages are low cost and ease of distribution. Unfortunately, the
Intensive Interventions
efficacy of self-​help materials appears to be quite limited, with im-
proved cessation rates of about 1% compared to no-​treatment con- The most intensive interventions tend to be multisession treat-
trols.4 However, a self-​help intervention that extends over time (i.e., ments typically offered through smoking cessation clinics, in either
distribution of sets of materials over 12–​18 months) has recently group or individual formats. Of the empirically supported intensive
demonstrated long-​term efficacy.10 interventions, the most common approach is cognitive-​behavioral
counseling. Key elements of this approach include patient education
Telephone Quitlines regarding tobacco dependence and withdrawal, advice for coping
Smoking cessation quitlines are available throughout the United with withdrawal symptoms, identifying high-​risk situations (“trig-
States and most of the world. In the United States one number gers”) that produce urges to smoke, teaching and practicing cogni-
(1-​800-​QUIT-​NOW) serves as a central access point that auto- tive and behavioral responses for coping with urges, discussion of
matically routes calls to the appropriate state or federal quitline long-​term risk factors such as depression and weight gain, and dis-
service. Approximately 400,000 smokers in the United States are cussion of how to respond in the event of an initial “slip” or “lapse.” It
served annually by state quitlines, with an average utilization rate usually involves multiple sessions over several weeks and may begin
of about 1%.11 before the target quit date. Counseling has been found to be effec-
Quitline services differ in the amount and frequency of coun- tive, with an odds ratio of 1.5 compared to no counseling and an
seling offered, the provision of ancillary materials, referrals to local average abstinence rate of 16.2% compared to 11.2%.4 In addition
smoking cessation agencies, the provision of free or subsidized to counseling, the guideline also found evidence for intratreatment
pharmacotherapies, and whether calls are proactive (call-​out), re- social support, and it therefore recommends providing support and
active (call-​in), or both. Quitlines have the advantage of providing encouragement as part of treatment.
10 SECTION I Factors in Cancer Risk and Prevention

Combining Counseling and Pharmacotherapy diagnosis and end of treatment may represent the optimal window
A key conclusion of the most recent guideline is that the combina- of opportunity for provision of smoking cessation interventions.
tion of counseling and medication is more effective than either alone There is less research on long-​term abstinence rates among cancer
in producing long-​term tobacco abstinence. Moreover, as noted patients. Estimates of smoking relapse range from 13% to 60%.
earlier, higher abstinence rates tend to be produced with more in- Unlike the general population of smokers for whom relapse most
tensive counseling. Thus, the guideline meta-​analysis produced an often occurs within a week after cessation, the majority of relapses
estimated abstinence rate of approximately 33% when medication among cancer patients occurs within the first few months following
was combined with nine or more sessions of counseling, compared a quit attempt, again reflecting the initial motivational impact of a
to 22% when no more than one counseling session was provided. cancer diagnosis. Predictors of both persisting smoking and relapse
Conversely, the guideline reported an odds ratio of 1.7 for the com- have included factors such as longer history of smoking, depression,
bination of medication and counseling, compared to counseling lower desire to quit, and alcohol use.17
alone.4 Counseling and medication appear to provide complemen- Interventions for Cancer Patients
tary benefits. Whereas medication reduces withdrawal symptoms
and craving, counseling can teach cognitive and behavioral coping Few clinical trials have been conducted on smoking cessation inter-
strategies and can provide valuable social support. Therefore, when- ventions for cancer patients. Interventions tested have included a
ever medication is recommended or provided to patients, they variety of formats, such as nurse-​delivered inpatient counseling,
should also be offered counseling. cognitive-​behavioral therapy, motivational interviewing, distribu-
tion of educational materials, and follow-​up phone calls. Several
studies have also tested pharmacological cessation treatments (nic-
Special Issues with Cancer Patients otine replacement therapy, varenicline, or bupropion), either alone
or combined with counseling. The overall findings have not demon-
There is a growing body of evidence that smoking following cancer strated a significant treatment effect.18
diagnosis has a negative impact on cancer treatment efficacy, More recently, some innovative interventions are being tested.
treatment-​related complications and side effects, cancer recurrence System-​ based interventions aim at introducing changes in the
and second malignancies, and overall survival.13 With advances in overall organization to change smoking cessation practices (e.g.,
cancer treatments, the number of cancer survivors is significantly automatic referrals using EHRs). Also, interventions using mobile
increasing, emphasizing the importance of improving health out- technology have been pilot tested. However, evidence on the effec-
comes and quality of life within this high-​risk population. In this tiveness of these new types of interventions is still limited.
section, we will describe the benefits of smoking cessation in cancer Finally, the use of e-​cigarettes has increased among cancer pa-
patients, review cessation and relapse rates among cancer patients, tients, paralleling trends in the general population.19 Overall, it seems
and summarize the current knowledge regarding cessation inter- that cancer patients hold generally positive expectancies regarding
ventions for cancer patients. e-​cigarettes, as compared to both combustible cigarettes and NRT,
and find them an attractive way to quit smoking.20 The American
Benefits of Quitting Smoking Association for Cancer Research (AACR) and the American Society
The last report of the U.S. Surgeon General concluded that con- of Clinical Oncology (ASCO) recommend that healthcare providers
tinued smoking after cancer diagnosis is causally related to multiple encourage use of FDA-​approved cessation methods, given the lack
negative consequences, including increased risk of cancer-​specific of definitive data regarding the safety and efficacy of e-​cigarettes.
mortality as well as all-​cause mortality. Furthermore, persistent However, the American Cancer Society’s 2018 position statement on
smoking after a cancer diagnosis has been strongly associated e-​cigarettes recommends harm reduction, including e-​cigarettes, for
with cancer recurrence, poor treatment outcomes (e.g., poorer re- patients who have not otherwise been able to quit smoking.
sponse to treatment, treatment-​related toxicities), and higher risk of When implementing smoking cessation interventions with
hospitalization.13 cancer patients, clinicians should be mindful of several unique
Quitting smoking is associated with fewer medical complications, cancer-​related issues. For instance, the delay in relapse among
decreased risk of subsequent malignancies, and increased survival cancer patients described earlier may suggest a waning of motiva-
rate.14 Finally, some research indicates that patients who remain tion as patients physically recover and return to their prediagnosis
smoke-​free following cancer treatment report lower levels of depres- lifestyles. Thus, smoking relapse prevention interventions may be
sion and fatigue, improving overall quality of life relative to patients particularly important as patients recover. Another issue relates to
who continue to smoke.15 In summary, evidence is accumulating potential contraindications with the use of smoking cessation phar-
that smoking cessation after a cancer diagnosis improves quality of macotherapy. With respect to NRT and e-​cigarettes, for example,
life, increases survival, and decreases cancer recurrence and psycho- although nicotine is not itself carcinogenic, preclinical research sug-
logical distress. gests that it can accelerate tumor growth, inhibit apoptosis induced
by several chemotherapy agents, and negatively impact response to
Smoking Cessation and Relapse among Cancer Patients radiotherapy. Nevertheless, there is no evidence to date indicating
Despite the benefits of quitting, over 30% of cancer patients con- that NRT causes adverse events in cancer patients.14 In addition,
tinue to smoke after diagnosis. However, cancer patients who smoke NRTs such as nicotine gum, spray, inhaler, or lozenge may not be
are highly motivated to quit, and many make an attempt to quit at appropriate for individuals with oral cancers, whereas bupropion is
the time of diagnosis.16 Because most quit attempts appear to occur contraindicated for patients with a history of central nervous system
at the time of diagnosis and treatment, the period between cancer (CNS) tumors due to an increased risk of seizures. Hence, clinicians
CHAPTER 1 Tobacco Use and Cessation 11

must take extra care in selecting appropriate cessation medications establishment of smoke-​free campuses by hospital administrators,
that address cancer patients’ unique needs. and strong cessation advice and assistance by every healthcare pro-
Given the growing body of evidence demonstrating the substan- vider. Finally, the changing demographics of tobacco users along
tial risks of continued smoking among cancer patients, it is not with evolving noncombustible alternatives to smoking require on-
surprising that recognition and support of cessation services are going monitoring and the updating of policies and clinical practices,
increasing. For example, the ASCO developed updated tobacco as needed.
guidelines that include recommendations for health professionals to
assess tobacco use and integrate cessation services in the oncology
setting.21 Similarly, a policy statement by the AACR called for im- ACKNOWLEDGMENTS
proved documentation of tobacco use among patients, as well as
Preparation of this chapter was supported by National Cancer
improvements in evidence-​based cessation assistance provided to
Institute grants R01 CA154596, R01 DA037961, R01 CA199143,
all patients who use tobacco or have recently quit tobacco.22 The
and R03 CA227044.
National Comprehensive Cancer Network (NCCN) has also de-
Disclosure: Dr. Brandon has received research support from
veloped clinical practice guidelines for smoking cessation that in-
Pfizer, Inc., and serves on the advisory board for Hava Health, Inc.
  
clude a thorough assessment of tobacco use and supports the use
of evidence-​based methods of smoking cessation (i.e., combined
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2
Diet and Cancer
Marian L. Fitzgibbon, Lisa Tussing-​Humphreys, Angela Kong, and Alexis Bains

Overview types protects against excessive weight gain and obesity. Thus, the
interaction of energy intake (i.e., diet) and energy expenditure (i.e.,
Research over the past several decades shows that 95% of cancers physical activity) is fundamental to weight management and cancer
can be attributed to environmental factors,1 including pollution, in- risk and control. This chapter (1) summarizes the role of dietary fac-
fections, radiation, and other external factors as well as tobacco use, tors and cancer risk, (2) highlights the relationship between dietary
alcohol, inactivity, diet, and other lifestyle factors.2 Diet, arguably patterns and cancer, (3) summarizes the role of weight management
among the most modifiable of these factors, likely contributes to the and energy balance, (4) identifies potential environmental barriers
development of 30% to 35% of cancers. to diet-​related cancer risk reduction, and (5) offers areas for future
Substantial shifts in the food landscape in developed countries research.
have contributed to changes in dietary intake, energy balance, in-
creases in body fat, and the development of obesity. Obesity, de-
fined as a body mass index (BMI) ≥ 30 kg/​m², is associated with Diet-​, Physical Activity–​, and Body Composition–​
several cancers. Obesity exceeds 30% in both genders and is pre- Related Factors and Cancer Risk
dicted to reach 51% by 2030 across all adult age groups in the United
States (U.S.). Thus, the World Cancer Research Fund (WCRF), the This section presents an overview of the best-​established associ-
American Institute for Cancer Research (AICR), the American ations (i.e., graded as “strong evidence”) reported by the WCRF and
Cancer Society (ACS), and cancer researchers both in the U.S. and the AICR between the leading causes of cancer death worldwide and
globally are devoting significant time and resources to studying the dietary factors, physical activity, and body fatness4 (summarized in
relationship between diet, dietary patterns, lifestyle risk factors, obe- Table 2.1).
sity, and cancer.3 Lung Cancer. Lung cancer is the most common cause of cancer
Advances in research methodology hold promise for reconciling and cancer death in both sexes combined worldwide. Smoking is the
the complex literature on the role of diet and cancer risk. Prior re- main cause of lung cancer globally, accounting for an estimated 90%
search focused more often on specific nutrients and foods in isola- of lung cancers among men and 80% in women. Arsenic in drinking
tion rather than examining the effects of dose, timing, exposure, and water is the most established dietary risk factor for lung cancer.
overall nutritional status. However, more recent studies demonstrate The World Health Organization (WHO) reports that contaminated
that dietary patterns are key to enhancing our knowledge of the rela- groundwater is the main source of arsenic.5 Beta-​carotene supple-
tionship between diet and cancer. The consensus across studies sug- ments are also associated with increased risk for lung cancer, par-
gests that a healthy dietary pattern includes fruits, vegetables, fish, ticularly among smokers. This association was discovered through
whole-​grain cereals, nuts, legumes, and intake of healthy fats. This is two large intervention trials, the Beta-​carotene and Retinol Efficacy
presumably due to the value of these foods in providing a combina- Trial (CARET) and the Alpha-​Tocopherol, Beta-​Carotene (ATBC)
tion of important vitamins, minerals, fiber, protein, and antioxidants Cancer Prevention Study.6 The CARET study was conducted in the
associated with reduced cancer risk. An unhealthy dietary pattern, U.S. with male and female smokers and former smokers, as well as
on the other hand, consists of red meat, processed meat, refined men with occupational exposure to asbestos. The ATBC Cancer
sugars and sugar-​sweetened beverages, refined flours, alcohol, and Prevention Study was conducted in Finland with male smokers.
high saturated fat intake. There is only limited evidence of specific foods decreasing (e.g.,
While diet is often a major contributor to the energy imbalance vegetables, fruits, foods containing carotenoids, etc.) or increasing
that can lead to the development of obesity, physical activity pat- (e.g., red meat, processed meat, alcohol) lung cancer risk.
terns also play a role. Extensive evidence shows increased physical Liver Cancer. Liver cancer is the fourth most common cause of
activity may reduce the incidence of and survival from various can- cancer death worldwide and the fifth most commonly occurring
cers and that inactivity is associated with many chronic diseases. cancer. Established risk factors of liver cancer include cirrhosis of the
Strong evidence demonstrates that regular physical activity of all liver, long-​term use of high-​dose estrogen and progesterone, chronic
14 SECTION I Factors in Cancer Risk and Prevention

Table 2.1. Dietary-​, Physical Activity–​, and Weight-​Related Factors Showing Convincing or Probable Evidence of Association with the Top 10
Causes of Cancer Death Worldwide

Cancer Increases Risk Decreases Risk

Lung Arsenic in water**
High-​dose beta-​carotene supplements1**
Liver Exposure to aflatoxin2**
Alcohol (45 grams or 3 drinks a day)**
Body fatness (based on BMI)**
Coffee*
Stomach Body fatness (cardia) (based on BMI)*
Alcoholic drinks (45 grams or 3 drinks a day)*
Food preserved by salting3*
Colorectal Processed meat4** Physical activity7**
Alcoholic drinks (30 grams or 2 drinks a day)** Whole grains*
Body fatness5 Foods containing dietary fiber8*
Adult attained height6** Dairy products9*
Red meat (beef, pork, lamb, and goat from domesticated animals)* Calcium supplements* (supplemental dose of
200–​1,000 mg/​day) *
Breast Premenopausal Vigorous physical activity*
Adult attained height6** Body fatness11*
Alcoholic drinks (no amount/​limit was found)* Lactation12*
Greater birthweight10* Physical activity13*
Postmenopausal Body fatness in young adulthood11*
Alcoholic drinks (no amount/​limit was found)** Lactation12*
Body fatness5**
Adult weight gain**
Adult attained height6**
Esophageal Adenocarcinoma
Body fatness5**
Squamous Cell Carcinoma
Alcoholic drinks**
Mate14*
Pancreatic Body fatness15**
Adult attained height6*
Prostate Body fatness (advanced prostate cancer)16*
Adult attained height6*

** Indicates convincing evidence.

* Indicates probable evidence.
Based on the grading criteria reported in the Diet, Nutrition, Physical Activity and Cancer: A Global Perspective, Third Expert Report (2018).
** Convincing (strong evidence): Evidence strong enough to support a judgment of a convincing causal (or protective) relationship, which justifies making
recommendations designed to reduce the risk of cancer. The evidence is robust enough to be unlikely to be modifiable in the foreseeable future as new evidence
accumulates.
* Probable (strong evidence): Evidence strong enough to support a judgment of a probably causal (or protective) relationship, which generally justifies recommendation designed to reduce the
risk of cancer.
1
Based on studies testing high-​dose supplements on smokers and former smokers (beta carotene: 20 mg/​day or retinol: 25,000 IU/​day).
2
Grains (cereals), legumes (pulses), seeds, nuts, and some fruits and vegetables are foods that may be contaminated with aflatoxins.
3
Regarding traditionally prepared in East Asia, high-​salted foods and foods preserved with salt, such as pickled vegetables and salted or dried fish.
4
Regarding meat preserved by smoking, curing, slating, or adding chemical preservatives.
5
Body fatness represents BMI (body mass index), waist circumference, or waist-​hip ratio.
6
Adult attained height is an indicator of genetic, environmental, hormonal, and nutritional growth factors that have an influence on growth from preconception to completion of
linear growth.
7
Includes physical activity of all types: occupational, household, transport, and recreational. The panel judges that the evidence for colon cancer is convincing, but no conclusion was
drawn for rectal cancer.
8
Both foods that naturally have dietary fiber and foods with dietary fiber added.
9
Evidence from dairy, milk, cheese, and dietary calcium supplements.
10
“The Panel’s conclusion relates to the evidence for overall breast cancer (unspecified). The observed association was in estrogen-​receptor-​negative (ER–​) breast cancer only.”
11
Body fatness represents BMI, waist circumference, or waist-​hip ratio. Women 18 to 30 years old included in evidence. For young adults, body fatness represents BMI.
12
“The Panel’s conclusion relates to the evidence for overall breast cancer (unspecified). The evidence for premenopausal and postmenopausal breast cancers separately was less
conclusive, but consistent with the overall finding.”
13
“Physical activity including vigorous, occupational, recreational, walking and household activity.”
14
Beverage is consumed scalding hot and through a metal straw (as traditionally consumed in South America).
15
Body fatness referring to/​interconnected with fat distribution, BMI, abdominal girth, and adult weight gain.
16
Body fatness represents BMI, waist circumference, or waist-​hip ratio. This outcome was seen in advanced cancer only, meaning high-​grade and fatal prostate cancers.
CHAPTER 2 Diet and Cancer 15

viral hepatitis, and smoking. There is strong evidence that the fol- and dairy products also appear to reduce colorectal cancer risk,
lowing diet-​and weight-​related factors increase liver cancer risk: (1) though the effect for milk is, in part, mediated by calcium. Evidence
being overweight or obese (as assessed by BMI), (2) alcoholic drinks for calcium’s protective effects is based on studies of supplements at
(about 3 drinks/​day), and (3) exposure to aflatoxins. Aflatoxin, a doses of 200 to 1,000 mg/​day.
mold that develops on foods stored in hot, wet conditions, can con- Breast Cancer. Breast cancer is the most frequently occurring
taminate foods such as cereals (grains), legumes, seeds, and nuts, cancer and the most common cause of cancer death for women
and some fruits and vegetables. Coffee consumption is the only diet-​ worldwide. Because it is a hormone-​related cancer, risk is most af-
related factor that is protective. A dose-​response meta-​analysis of fected by factors that influence exposure to estrogen, including
existing studies conducted by the expert panel suggests that one cup menopausal status. In a recent update by the WCRF/​AICR, the
of coffee per day is associated with a 14% decreased risk.4 following factors were considered strong evidence (convincing)
Stomach (Gastric) Cancer. Stomach cancer is the fourth most for increasing risk of postmenopausal breast cancer: (1) alcoholic
common cancer worldwide, with the highest incidence noted drinks (no amount identified), (2) body fatness, (3) adult weight
among men and in certain regions of Asia, and is the third most gain, and (4) adult attained height.4 Adult attained height (a marker
common cause of cancer death. Based on the location of the tumor, for factors affecting growth) and alcohol intake also increase risk
stomach cancer can be classified as cardia (top part and closest to for premenopausal breast cancer. Additionally, greater birthweight,
esophagus) and noncardia (all other regions). Stomach cardia can- which is an indicator of prenatal growth and fetal nutrition, is also
cers are more common in the U.S. and UK, while noncardia forms recognized as a risk factor for premenopausal women. While body
of stomach cancer are more prevalent in Asia. However, incidence fatness increases breast cancer risk for postmenopausal women, it is
rates of stomach cancer (particularly noncardia) are declining actually protective for premenopausal women. Lactation and phys-
worldwide due in part to more widespread use of refrigeration to ical activity decrease risk for both pre-​and postmenopausal women.
store foods (rather than salting) and a decrease in Helicobacter pylori However, evidence is insufficient to confirm protective effects of any
(H. pylori) infections. Smoking and exposure to industrial chemi- specific dietary factors.
cals are other established contributors to stomach cancer. Diet-​and Esophageal Cancer. Cancer of the esophagus is the sixth most
body composition–​related factors that increase the risk of stomach common cause of cancer death and the seventh most common cancer
cancer include alcoholic drinks (three drinks/​day), high-​salt foods, worldwide. There are two main types of esophageal cancer: squa-
and obesity. Being overweight or obese increases the risk of stomach mous cell carcinoma (affects the upper part of the esophagus) and
cardia cancer in particular. adenocarcinoma, which occurs in the region between the esophagus
Colorectal Cancer. Colorectal cancer is the third most commonly and stomach. Risk factors vary by site. For instance, body fatness
diagnosed cancer and the second most common cause of cancer increases the risk for esophageal adenocarcinoma but not squamous
deaths worldwide. Diet, physical activity, obesity, and alcohol con- cell. Squamous cell carcinoma can be impacted by diet-​related fac-
sumption influence risk. The factors with the strongest evidence for tors. For instance, intake of alcohol and mate are associated with
increasing risk are (1) processed meat intake, (2) alcoholic drinks increased risk of squamous cell carcinoma rather than adenocar-
(about two drinks/​day), (3) body fatness, (4) adult attained height, cinoma. Mate is a tea-​like beverage consumed in parts of South
and (5) red meat. Adult attained height is not a direct risk factor, America, usually scalding hot, through a metal straw.
but rather a marker for factors (e.g., genetic, environmental, hor- Pancreatic Cancer. Pancreatic cancer is the seventh most
monal, and nutrition) that could impact growth during the develop- common cause of cancer deaths. Incidence is higher in men than
mental years. Red meat contains the iron-​containing protein heme, in women and higher in developed countries. The WCRF/​AICR’s
which can facilitate the formation of potentially carcinogenic com- continuous update project concluded there is convincing evidence
pounds. Also, red meat cooked at high temperatures can produce that body fatness and adult attained height increase pancreatic
heterocyclic amines and polycyclic aromatic hydrocarbons that may cancer risk.4 No convincing or probable evidence suggests that any
contribute to colon cancer in people with a genetic predisposition. dietary factors increase risk, though limited data suggests that red
Processed meats (e.g., ham, bacon, sausages, canned meats) are pre- and processed meats, alcohol, high-​fructose foods/​beverages, and
served by methods other than freezing, such as smoking, salting, air foods containing saturated fatty acids increase risk. Coffee was pre-
drying, or heating. Strong evidence of factors decreasing risk include viously considered a possible risk factor, but the updated report in-
(1) physical activity, (2) whole grains, (3) dietary fiber, (4) dairy dicates this is unlikely. No food or nutrition factors are identified as
products, and (5) calcium supplements. Of these factors, the most decreasing pancreatic cancer risk.
convincing evidence is based on studies examining physical activity Prostate Cancer. Prostate cancer is the second most common
(e.g., occupational, household, transport, and recreational) and co- cancer and fifth most common cause of cancer death in men.
lorectal cancer. Based on a meta-​analysis of over 30 studies, a re- Incidence is much higher in developed countries. The WCRF/​
duced risk of about 14% for colon cancer was observed comparing AICR’s continuous update project report suggests there is strong
those in the highest vs. lowest groups for physical activity (risk ratio probable evidence that body fatness and adult attained height in-
[RR] = 0.85; 95% confidence interval [CI]: 0.78–​0.91).4 For whole-​ crease prostate cancer risk. However, insufficient data exists to iden-
grain consumption there was a reduced risk of 17% per 90 g/​day tify any dietary factor as risk promoting.4
of whole-​grain intake (based on six studies consisting of n = 8,320 Cervical Cancer. Cervical cancer ranks fourth in both mortality
cases).4 For fiber-​containing foods, which include fiber that is added and incidence for women worldwide. The primary risk factor is infec-
and naturally occurring, there was a reduced risk of 9% per 10 g/​ tion with human papilloma viruses. Food and nutrition do not play
day (based on 15 studies consisting of n = 14,876 cases).4 Calcium a significant role in increasing or decreasing cervical cancer risk.4
16 SECTION I Factors in Cancer Risk and Prevention

Dietary Patterns and Cancer Risk studies examining diet quality, using several metrics including
the HEI and various health outcomes, found that individuals con-
Single foods and nutrients are not typically consumed in isolation. suming the highest-​quality diets compared to lowest-​quality diets
Because dietary nutrients are consumed in combination, syner- had a 16% reduction in cancer mortality or incidence (RR = 0.84;
gistic effects between food and nutrients may create a metabolic 95% CI: 0.82–​0.87).9
milieu that prevents or promotes carcinogenesis. This section pre- Ecological studies suggest overall cancer risk is lower in
sents an overview of dietary patterns and associations with cancer Mediterranean countries versus northern Europe, the UK, and the
risk and risk of cancer-​related mortality as indicated by studies U.S. Many have attributed this distinction to the customary foods
that examined adherence to science-​based public health dietary re- consumed by people residing in this region. A Med Diet pattern
commendations such as the U.S. government’s Dietary Guidelines is one in which vegetables and whole grains feature prominently,
for Americans (DGAs) and Mediterranean and vegetarian dietary fresh fruit is a typical dessert, olive oil is the main fat source,
patterns. The DGAs and a Mediterranean diet (Med Diet) pattern animal-​based protein intake is limited, and wine is consumed in
have corresponding index scores that are used to quantify adherence moderation, with meals. Mechanistically, it is hypothesized that
using a standardized approach.7 certain aspects of the Med Diet, including a healthy fatty acid ratio
The DGAs are designed to promote good health and reduce the and foods rich in antioxidants and anti-​inflammatory nutrients,
risk of chronic diseases, including cancer. The guidelines are re- work synergistically to promote reduced systemic inflammation
vised every five years to account for advances in scientific know- and down-​regulation of pro-​carcinogenic pathways. Several re-
ledge pertaining to diet and disease relationships (the current search groups have developed scoring indices to operationalize
DGAs are presented in Table 2.2). The Healthy Eating Index (HEI) and assess adherence to a Med Diet pattern to relate to disease
is a scoring tool that measures adherence to a given set of DGAs; outcomes. The Alternate Mediterranean Diet (aMED) score is a
higher scores are indicative of greater adherence to the guidelines.8 Med Diet adherence score developed specifically for U.S. popula-
A recent systematic review and meta-​analysis of prospective cohort tions.10 The aMED has nine components, with one point awarded

Table 2.2. Dietary and Lifestyle Recommendations for Good Health and Cancer Prevention

2015–​2020 Dietary Guidelines for Americans35 General Mediterranean Diet American Cancer Society37 American Institute for Cancer Research38
Characteristics36
5 overarching guidelines of a healthy eating • Daily abundance of plant-​ • Achieve and maintain • Be a healthy weight.
pattern: based foods including whole a healthy weight • Be physically active.
• Follow a healthy eating pattern across the grains, vegetables, fruits, and throughout life. • Eat a diet rich in whole grains,
lifespan. legumes. • Be physically active. vegetables, fruits, and beans.
• Focus on variety, nutrient density, and • Olive oil used daily as the • Limit time spent sitting. • Limit consumption of “fast food” and
amount. principal fat source. • Eat a healthy diet, with an other processed foods high in fat,
• Limit calories from added sugars and • Low to moderate daily emphasis on plant foods. starches, or sugars.
saturated fats and reduce sodium intake. consumption of low-​fat • Choose foods and drinks in • Limit consumption of red meat and
• Shift to healthier food and beverage choices. dairy foods. amounts that help you get processed meat.
• Support healthy eating patterns for all. • Animal-​based protein to and maintain a healthy • Limit consumption of sugar-​sweetened
A healthy eating pattern includes: consumed in low to moderate weight. beverages.
• A variety of vegetables from all the amounts weekly or monthly. • Limit how much processed • Limit alcohol consumption.
subgroups—​dark green, red and orange, • Sweets consumed in low meat and red meat you eat. • Do not use supplements for cancer
legumes (beans and peas), starchy, and other. amounts monthly. • Eat at least 2½ cups of prevention.
• Fruits, especially whole fruits. • Wine in moderation vegetables and fruits • For mothers: breastfeed your baby if
• Grains, at least half of which are whole grains. with meals. each day. you can.
• Fat-​free or low-​fat dairy, including milk, • Be physically active. • Choose whole grains • After a cancer diagnosis: follow our
yogurt, cheese, and/​or fortified soy beverage. instead of refined grain recommendations if you can.
• A variety of protein foods, including seafood, products.
lean meats and poultry, eggs, legumes (beans • If you drink alcohol, limit
and peas), and nuts, seeds, and soy products. your intake.
• Oils.
A healthy eating pattern limits:
• Saturated fats (<10% calories per day) and
trans fats, added sugars (<10% of calories per
day), and sodium (<2,300 mg per day).
• If alcohol is consumed, it should be
consumed in moderation—​up to one drink
per day for women, and up to two drinks
per day for men—​and only by adults of legal
drinking age.
Healthy Eating Patterns Dietary Principles:
• An eating pattern represents the totality of all
foods and beverages consumed.
• Nutritional needs should be met primarily
from foods.
• Healthy eating patterns are adaptable.
Meet the Physical Activity Guidelines for
Americans.
CHAPTER 2 Diet and Cancer 17

for scoring higher than the median intake within a given popula- Diet and Weight Loss Intervention Trials: Effects
tion/​cohort for whole grains, fruits, vegetables (except potatoes), on Cancer-​Related Outcomes
nuts, fish, legumes, and monounsaturated versus saturated fat
ratio; one point is awarded for red and processed meat below the This section presents an overview of several large randomized trials
median; and one point is awarded for consuming one alcoholic designed to examine the effects of dietary factors and weight loss
beverage daily. In the National Institutes of Health–​American on cancer prevention or control and cancer risk–​related biomarkers.
Association of Retired Persons (NIH-​AARP) Diet and Health
observational cohort study, greater adherence to a Med Diet pat- Increasing Fiber, Fruits, and Vegetables and Decreasing
tern (aMED scores ranging from six to nine points) was associ- Total Fat
ated with decreased risk of cancer-​related mortality in both men The Women’s Health Initiative (WHI). The WHI was a study of
and women.11 Regarding site-​specific cancers, greater adherence over 45,000 postmenopausal women (1993–​2004) that included a
to a Med Diet, based on aMED, was associated with lower colo- clinical trial with three intervention arms, including two that were
rectal cancer risk in men in a combined analysis of the Nurses’ diet and cancer related. The first of these tested a low-​fat eating pat-
Health Study and Health Professionals Follow-​up Study,12 and tern (less than 20% of total calories; five servings/​day of fruits and
decreased risk of lung cancer in both men and women in the vegetables; six servings/​day of whole grains) on breast cancer and
NIH-​AARP cohort, with an even more profound risk reduction colorectal cancer. Control participants received information con-
in current and former smokers.13 However, not all studies have sistent with the U.S. Department of Agriculture DGAs. Follow-​up at
shown a strong association between Med Diet adherence and 8.1 years showed no significant reduction in the incidence of breast
decreased cancer risk and mortality. For example, in the French cancer or colon cancer among women in the intervention group.21
NutriNet-​Santé cohort study, greater adherence to a Med Diet, The second arm examined the effects of calcium and vitamin D sup-
based on the Medi-​Lite score, was not associated with decreased plementation on colorectal cancer. Over an average of seven years,
risk of breast (women), colorectal, or prostate cancer (men).14 In no significant difference was observed in colorectal cancer incidence
the Multiethnic Cohort study, greater adherence to a Med Diet, between the intervention and control groups.22 The extended period
based on aMED, was associated with lower colorectal cancer mor- over which colorectal cancer develops may have led to these null
tality among African American cancer survivors but not Native findings. In recent secondary analyses, vitamin D and calcium sup-
Hawaiian, Japanese American, Latino, and white survivors.15 An plementation were not associated with reduced invasive cancer risk
important issue with the literature examining associations be- or mortality,23 whereas vitamin B6 and riboflavin intake were associ-
tween Med Diet adherence and cancer risk and mortality is the ated with lower colorectal cancer risk.23
use of different scoring approaches to assess Med Diet adherence. Women’s Intervention Nutrition Study (WINS). This phase III
However, in the European Prospective Investigation into Cancer clinical trial (1994–​2001) was designed to examine the relationship
and Nutrition (EPIC) study, researchers investigated three dif- between dietary fat intake and breast cancer among 2,437 women
ferent Med Diet scores (Mediterranean Diet Score [MDS], rela- with resected, early-​stage breast cancer. Women in the intervention
tive Med Diet Score [rMED], and the Mediterranean Style Dietary group were counseled to reduce dietary fat intake to 15% of calories
Pattern Score [MSDPS]) and associations with overall cancer during a four-​month intervention period. The comparison group re-
mortality. Comparing the highest versus lower quartile for each ceived no dietary counseling. Interim results at 60 months showed
score, higher Med Diet adherence was associated with signifi- dietary fat intake and body weight were significantly lower in the
cantly lower risk of cancer-​related mortality irrespective of the intervention group compared to the control group.24
scoring approach used.16 Women’s Healthy Eating and Living (WHEL) Study. This ran-
The association between a vegetarian dietary pattern and re- domized trial (1995–​2006) assessed whether a significant increase in
duced cancer risk stems from studies of the Seventh Day Adventist vegetable, fruit, and fiber intake and a decrease in dietary fat intake
religious sect whose doctrine advises against eating animal flesh. could reduce the risk of recurrent and new primary breast cancer
Seventh Day Adventists adhering to a vegetarian eating pattern and “all cause” mortality among 3,088 survivors of early-​stage breast
had lower rates of cancer overall, lower rates at specific sites cancer. Women in the intervention were instructed to consume daily
such as the prostate and colon, and lower risk of cancer-​related five vegetable servings plus 16 ounces of vegetable juice, three fruit
mortality compared to the general U.S. population.17 However, servings, 30 grams of fiber, and 15% to 20% of energy intake from
Seventh Day Adventists also typically abstain from tobacco and fat. Women in the comparison group received written materials con-
alcohol, which may contribute to the observed health effect. In sistent with the “5-​a-​Day” fruits and vegetables message. Although
the EPIC cohort, vegetarianism was associated with lower overall the intervention group did adhere to the prescribed diet, there was
cancer risk and risk for stomach and bladder cancer, but no ef- no effect on breast cancer events or mortality among early-​stage
fect was observed for colorectal and prostate cancer incidence breast cancer survivors.25
compared to nonvegetarians.18 Studies of breast cancer incidence
and mortality have not demonstrated differences between vege- Mediterranean Diet
tarians and nonvegetarians, although there is some evidence that Only two studies have tested the effect of a Med Diet on cancer risk
a vegan diet pattern can reduce breast cancer risk.19 Moreover, in the context of a randomized controlled trial.
a vegan diet pattern was associated with statistically significant Lyon Diet and Heart Study. Six hundred and five adult survivors
protection from overall cancer incidence in the Adventist Health of a first acute myocardial infarction were randomized to a Med
Study-​2.20 Diet–​type pattern or control (Step 1 diet of the American Heart
18 SECTION I Factors in Cancer Risk and Prevention

Association) over a four-​to five-​year timeframe.26 A secondary patients31 over a 23-​year period. In a large population-​based co-
outcome of the study was the occurrence of malignant tumors. hort study in the United Kingdom of 8,794 obese patients that
Seventeen cancers developed in the control group and seven in the underwent bariatric surgery (gastric banding, sleeve gastrectomy,
Med Diet group (RR = 0.39; 95% CI: 0.15–​1.01; p = 0.05). This study and gastric bypass), decreased risk of hormone-​related cancers in-
demonstrated for the first time in a randomized trial the cancer pro- cluding breast (odds ratio [OR] = 0.25; 95% CI: 0.19–​0.33), endo-
tective effect of a Med Diet in a non-​Mediterranean population. metrium (OR = 0.21; 95% CI: 0.13–​0.35), and prostate (OR = 0.37;
Prevención con Dieta Mediterránea (PREDIMED) Trial. 95% CI: 0.17–​0.76)32 was observed compared to obese patients not
Briefly, the PREDIMED study randomized 7,447 participants (4,282 undergoing a bariatric procedure that were propensity matched for
women) to a Med Diet supplemented with extra-​virgin olive oil, age, sex, comorbidity, and duration of follow-​up. However, in the
Med Diet supplemented with mixed nuts, or control (low-​fat diet) same study, there was no effect of gastric banding or sleeve gas-
intervention with a median follow-​up of 4.8 years.27 A secondary trectomy on esophageal or colorectal cancer and an increased risk
outcome of the trial was breast cancer incidence for women without of colorectal cancer in patients receiving gastric bypass. Suggested
a history of breast cancer (n = 4,152). Breast cancer rates per 1,000 mechanisms associated with this increase in risk include inflamma-
person-​years were 1.1 for the Med Diet plus extra-​virgin olive oil tion and hyperproliferation and gut microbiota changes following
group, 1.8 for the Med Diet nuts group, and 2.9 for the control group, the surgical bypass procedure.
respectively. Although the results come from a secondary analysis, Weight Management Lifestyle Interventions. Several studies
findings suggest a protective effect of a Med Diet supplemented with have examined how weight loss through calorie restriction, dietary
olive oil for the primary prevention of breast cancer. changes, and increased physical activity affects biological markers
related to cancer risk. For example, in the Nutrition and Exercise in
Effect of Diet on Premalignant Lesions and Women (NEW) study, 439 overweight and obese postmenopausal
Cancer-​Related Biomarkers women were randomized to aerobic exercise, dietary weight man-
Polyp Prevention Trial (PPT). The PPT28 was a randomized con- agement, or both versus control for 12 months.33 Compared to
trolled study of the effects of a low-​fat (20% of total energy intake), control, exercise plus diet-​induced weight loss was associated with
high-​fiber (18 g/​1,000 calories), high-​fruit and -​vegetable (five to significantly decreased BMI, insulin resistance, systemic inflam-
eight daily servings) diet on the recurrence of colorectal adenomas mation, sex steroid hormones, and genes related to growth factor
among individuals who had a polyp removed in the previous six signaling. Nonetheless, few studies have been able to discern the
months. At the four-​year follow-​up, results suggested that adopting a effect of behavioral weight management interventions on cancer-​
low-​fat, high-​fiber diet and increasing fruit and vegetable consump- specific outcomes (e.g., cancer risk, disease-​free survival).
tion did not affect the risk of recurrence for colorectal adenomas.
Controlled Feeding Studies. In a two-​week strictly controlled
diet exchange study in which native black Africans consumed an Challenges to Healthy Eating and Weight
animal-​based diet and African Americans consumed a plant-​based Management for Cancer Risk Reduction and
diet, colonic mucosal proliferation and inflammation were signif- Cancer Health Equity
icantly lower in the African Americans and significantly higher
postdiet in the native black Africans.29 The authors attributed the ef- As noted earlier and highlighted in consensus reports from leading
fect in the African Americans to changes in gut microbial metabolic cancer organizations, modifiable lifestyle behavioral risk factors,
function (i.e., increased short-​chain fatty acid production and de- including diet and physical inactivity, account for between 30%
creases in secondary bile acids) that was related to the diet switch. In and 50% of cancers. Often, the combination of less healthful diets
a crossover feeding trial conducted with relatively healthy men and and physical inactivity leads to excessive weight gain and obesity,
women, consuming a high (i.e., refined grains and added sugars) increasing cancer risk. Recent estimates reflect that obesity accounts
and low (i.e., high in whole grains, legumes, fruits, and vegetables) for 14% to 20% of the attributable cancer risk for U.S. adults and
glycemic index diet each for 28 days30 resulted in differing expres- as much as 50% of all cancers for individuals under age 65 years.
sion of plasma proteins related to carcinogenesis that was dependent In the most recent nationally representative survey of adults in the
on the subject’s baseline body adiposity (high vs. low fat mass). U.S. (2013–​2014), the age-​adjusted prevalence of obesity was 35.2%
Specifically, in response to the high-​glycemic-​load diet, those with among men and 40.4% among women. There were differences, how-
high fat mass had increased expression of plasma proteins related to ever, across race/​ethnicity, with prevalence rates of 38.7%, 57.2%,
cell cycle, DNA repair, and DNA replication that if sustained could and 46.6% among non-​Hispanic white, Non-​Hispanic black, and
lead to carcinogenesis. These findings suggest that obesity’s effect Hispanic women, respectively.34 The differences in prevalence
on cancer development may to some extent be tied to biological re- rates among men were not as striking, with rates of 35.4%, 38.2%,
sponse to differing dietary patterns. and 38.8% among non-​Hispanic white, non-​Hispanic black, and
Hispanic men, respectively.34
Effect of Weight Loss on Cancer-​Related Outcomes Unfortunately, minorities and low-​income individuals are at a
Surgically Induced Weight Loss. There is encouraging albeit significant disadvantage when it comes to making healthier dietary
conflicting evidence regarding the effect of surgical weight loss choices, driving obesity rates. For example, the main components of
on cancer risk. In a study of obese patients undergoing laparo- the Med Diet, which is embraced by the scientific community and
scopic gastric banding (n = 327) or medically induced weight loss associated with an inverse association with total mortality incidence
(n = 681), gastric banding was associated with significantly lower of coronary heart disease, stroke, and several cancers, are charac-
incidence of cancer and cancer-​related mortality in the surgical terized by a high consumption of vegetables, fruits, whole grains,
CHAPTER 2 Diet and Cancer 19

legumes, olive, and fish and a low intake of saturated fats, red meat, 6. Greenwald P. Beta-​carotene and lung cancer: A lesson for fu-
and dairy products. However, these foods tend to be more costly ture chemoprevention investigations? J Natl Cancer Inst.
than many energy-​dense foods that are discouraged in dietary re- 2003;95(1):E1.
commendations for cancer prevention. In addition, urban areas that 7. Chiuve SE, Fung TT, Rimm EB, Hu FB, McCullough ML, et al.
are often predominantly minority and/​or low income tend to offer Alternative dietary indices both strongly predict risk of chronic
disease. J Nutr. 2012;142(6):1009–​1018.
limited access to the foods recommended for cancer prevention,
8. Krebs-​Smith SM, Pannucci TE, Subar AF, Kirkpatrick SI, Lerman
and the built environment may offer fewer opportunities for safe
JL, et al. Update of the healthy eating index: Hei-​2015. J Acad Nutr
outdoor physical activity and introduce other factors that increase
Diet. 2018;118(9):1591–​1602.
cancer risk (e.g., higher rates of tobacco or alcohol use, increased 9. Schwingshackl L, Bogensberger B, Hoffmann G. Diet quality as as-
outlets selling alcohol and tobacco, and exposure to manufacturing sessed by the healthy eating index, alternate healthy eating index,
chemicals). dietary approaches to stop hypertension score, and health out-
comes: An updated systematic review and meta-​analysis of cohort
studies. J Acad Nutr Diet. 2018;118(1):74–​100.e11.
Conclusions and Future Research 10. Fung TT, Chiuve SE, McCullough ML, Rexrode KM, Logroscino
G, et al. Adherence to a DASH-​ style diet and risk of coro-
Primary prevention is possible through changes in modifiable risk nary heart disease and stroke in women. Arch Intern Med.
factors, including a healthful diet and regular physical activity, 2008;168(7):713–​720.
leading to maintenance of a healthy weight. We have reviewed pub- 11. Mitrou PN, Kipnis V, Thiebaut AC, Reedy J, Subar AF, et al.
lished guidelines from several agencies that made recommenda- Mediterranean dietary pattern and prediction of all-​cause mor-
tality in a us population: Results from the NIH-​AARP diet and
tions that have implications especially for the risk of colon, breast,
health study. Arch Intern Med. 2007;167(22):2461–​2468.
and lung cancer. Increasingly, we are understanding that the overall
12. Petimar J, Smith-​Warner SA, Fung TT, Rosner B, Chan AT, et al.
population’s health is dependent on identifying and intervening on
Recommendation-​based dietary indexes and risk of colorectal
upstream social determinants of health that address social and en- cancer in the nurses’ health study and health professionals follow-​
vironmental contextual factors that can drive unhealthful behavior. up study. Am J Clin Nutr. 2018;108(5):1092–​1103.
These factors can impede the ability of individuals to make choices 13. Anic G, Park Y, Subar A, Schap T, Reedy J. Index-​based dietary
consistent with reduced cancer risk. Further research can provide patterns and risk of lung cancer in the NIH–​AARP diet and health
a lens for population-​level action that can reduce lifestyle-​related study. Eur J Clin Nutr. 2016;70(1):123.
cancer inequities. 14. Lavalette C, Adjibade M, Srour B, Sellem L, Fiolet T, et al. Cancer-​
specific and general nutritional scores and cancer risk: Results
from the prospective Nutrinet-​ Sante cohort. Cancer Res.
ACKNOWLEDGMENTS 2018;78(15):4427–​4435.
15. Jacobs S, Harmon BE, Ollberding NJ, Wilkens LR, Monroe
Research reported in this publication was supported, in KR, et al. Among 4 diet quality indexes, only the alternate
part, by the University of Illinois Cancer Center, National Mediterranean diet score is associated with better colorectal
Institutes of Health’s National Cancer Institute, Grant cancer survival and only in African American women in the mul-
Numbers U54CA202995, U54CA202997, U54CA203000, and tiethnic cohort. J Nutr. 2016;146(9):1746–​1755.
T32CA057699. The content is solely the responsibility of the au- 16. Lassale C, Gunter MJ, Romaguera D, Peelen LM, Van der Schouw
thors and does not necessarily represent the official views of the YT, et al. Diet quality scores and prediction of all-​cause, cardiovas-
National Institutes of Health.
   cular and cancer mortality in a pan-​European cohort study. PLoS
One. 2016;11(7):e0159025.
17. Fraser GE. Associations between diet and cancer, ischemic
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20. Tantamango-​Bartley Y, Jaceldo-​Siegl K, Fan J, Fraser G. Vegetarian
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A, et al. Dietary fat reduction and breast cancer outcome: Interim scopic gastric banding) in comparison with medical treatment of
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Natl Cancer Inst. 2006;98(24):1767–​1776. 32. Mackenzie H, Markar SR, Askari A, Faiz O, Hull M, et al. Obesity
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3
Physical Activity, Sedentary Behavior,
and Cancer
Christine M. Friedenreich, Chelsea R. Stone, and Jessica McNeil

Introduction incidence. We then describe the hypothesized biologic mechanisms

that appear to explain the association between physical activity, sed-
Physical activity includes elements of planned, intentional activity entary behavior, and cancer incidence. We also report on the current
such as exercise but also extends further to include domains of burden of cancer that could be attributed to lack of physical activity
household, occupational, transportation/​ commuting, and recre- and sedentary behavior. Finally, we provide an overview of common
ational/​leisure activities. While the health benefits associated with barriers and facilitators to physical activity participation, as well as
regular physical activity for primary prevention of several chronic recent strategies and recommendations that have been suggested to
diseases have been well established, the benefits for cancer pre- promote physical activity participation and decrease sedentary time
vention have accumulated mainly in the last 30 years. Nearly 500 for cancer prevention.
observational epidemiologic and randomized controlled exercise
intervention trials have been conducted worldwide that have exam-
Epidemiologic Evidence
ined how physical activity is associated with cancer risk and what the
underlying biologic mechanisms are that could explain how physical
Physical Activity and Cancer Incidence
activity reduces cancer risk. Given this accumulating evidence base,
several national and international cancer agencies have adapted Literature Review Methods
physical activity guidelines developed for general health1 to specific We completed a systematic review of the scientific literature on all
guidelines for cancer prevention.2 English-​language articles published on PubMed (National Library
Emerging observational epidemiologic evidence also suggests of Medicine [NLM], National Institutes of Health [NIH]) through
that high amounts of sedentary time (e.g., too much sitting) in- July 1, 2019. Our search strategy combined terms for physical ac-
creases the risk of developing cancer, independently of physical tivity (exercise OR motor activity OR physical activity) as well as
activity levels.3 Similar to physical activity, sedentary behavior can search terms related to cancer (cancer OR tumor OR neoplasm).
be subdivided into different domains including occupational/​work- All articles were screened via titles and abstracts, with full-​text
place, transportation/​commuting, and recreational/​leisure seden- screening occurring for articles related to physical activity and
tary activities. Although current recommendations for sedentary cancer risk/​incidence. In instances where articles reported multiple
time are generic (e.g., limit total sitting time), the World Health domains of physical activity, we extracted the risk estimates for the
Organization (WHO) has suggested that the review of the scientific most comprehensive domain of physical activity (i.e., total physical
literature on sedentary behavior contributing to disease risk is a pri- activity or recreational physical activity). Additionally, we preferen-
ority area for the development of future physical activity guidelines tially extracted overall estimates over stratified results and estimates
amid the growing amount of research being conducted in this area.1 of reported lifetime physical activity. In the event that lifetime phys-
The World Cancer Research Fund (WCRF) and American Institute ical activity was not reported or assessed, we utilized estimates for
for Cancer Research (AICR) also recommend “limiting sedentary recent physical activity. Physical activity was self-​reported in these
habits/​sitting less” as part of their physical activity recommenda- studies and included a wide range of assessment methods that cap-
tions for cancer prevention.2 tured either current activity, activity in the past year, or activity over
In this chapter, we review the current observational epidemiologic lifetime with different units of measurement of activity. Since phys-
evidence on the association between physical activity and sedentary ical activity assessments varied across these studies, the estimates
behavior to cancer incidence. In addition, we review how specific extracted were those that compared the highest versus the lowest
types of activity (i.e., aerobic and resistance exercise training) and levels of activity in each study regardless of how these were defined.
how cardiorespiratory fitness may play an etiologic role in cancer Estimates were pooled using DerSimonian-​Laird random effects
22 SECTION I Factors in Cancer Risk and Prevention

models, and for the purpose of this review, we limit the discussion significant increased risks with higher levels of physical activity.
and presentation of results to cancer sites with 10 or more included Prostate cancer had the smallest protective effect with a hazard ratio
articles. of 0.94 (95% CI: 0.89–​0.99), though the summary estimate remained
statistically significant. Out of the 67 estimates combined, 18 of the
Overview of the Evidence estimates were statistically significant decreased risks (i.e., HR and
Through July 1, 2019, there were over 450 articles published 95% CI below 1 with increased levels of physical activity). Only
investigating the association between physical activity and cancer five studies found statistically significant increased risk of prostate
risk. Of these 450 papers, we found 10 cancer sites for which at least cancer. The remaining 44 studies reported nonstatistically signifi-
10 papers had been published. We estimated the summary risk esti- cant results.
mates and extracted information on the evidence of dose-​response Breast cancer had an overall summary estimate of 0.77 (95%
effects for bladder, breast, colorectal, endometrial, esophageal, CI: 0.75–​0.80) from 135 contributing estimates. Since there has
kidney, lung, ovarian, pancreatic, and prostate cancers as estimated been sufficient evidence published on the relation between phys-
in the individual studies (Table 3.1). The largest evidence base on ical activity and breast cancer incidence, detailed meta-​analyses
the association between physical activity and cancer risk exists for have been published on this topic. One such meta-​analysis sought
breast, colorectal, and prostate cancers with 132, 107, and 67 studies, to investigate the association of moderate-​to vigorous-​intensity rec-
respectively, contributing to each estimate. Evidence is also accumu- reational physical activity and breast cancer risk, stratified by men-
lating for associations between physical activity with lung (n = 44 opausal status.4 It was determined that estimates were similar for
studies), endometrial (n = 31), ovarian (n = 28), and pancreatic can- premenopausal and postmenopausal breast cancer risk, with risk
cers (n = 27). estimates of 0.80 (95% CI: 0.74–​0.87) and 0.79 (95% CI: 0.74–​0.84),
For these 10 cancer sites, there is consistent evidence that physical respectively. Dose-​response analyses were completed for premeno-
activity is associated with decreased cancer risk. The range of the pausal and postmenopausal breast cancer risk, for which curvilinear
effect sizes for the associations between physical activity and cancer trends were found, reflecting a point of diminishing returns with
risk was from 0.57 to 0.94, with the majority between 0.70 and 0.90. moderate-​to vigorous-​intensity recreational activity beyond 20–​30
The strongest effects were found for esophageal cancer, for which metabolic equivalents of task (MET)-​hours/​week.4
a hazard ratio (HR) of 0.57 (95% confidence interval [CI]: 0.42–​ There were 107 studies (127 estimates) contributing to the sum-
0.78) was estimated from the 13 studies and 14 estimates that were mary risk estimate of 0.75 (95% CI: 0.72–​0.79) between physical
combined for this summary effect estimate. There was consider- activity and colorectal cancer incidence. Similar to the level of ev-
able consistency across these studies, with 12 of the 14 estimates idence available for breast cancer, there have been targeted sys-
finding reduced risk of cancer associated with higher levels of phys- tematic reviews and meta-​analyses investigating this association.
ical activity and the two remaining studies finding nonstatistically More specifically, a review was completed that investigated the

Table 3.1. Summary of Epidemiologic Evidence on the Association between Physical Activity and Cancer Risk through July 1, 2019

Site No. of No. of Pooled 95% CI I2 Dose-​Response WCRF/​AICR PAGAC Grade

Studies Estimates Estimate Effect (%) Classificationa
Bladder 16 19 0.86 0.76–​0.97 76.5% 3 of 11 N/​A Strong
(27%)
Breast 132 135 0.77 0.75–​0.80 81.4% 58 of 97 Convincing decreases Strong
(60%) risk/​limited-​suggestive
decreases risk1
Colorectal 107 127 0.75 0.72–​0.79 70.5% 44 of 67 Convincing decreases Strongb
(66%) risk
Endometrial 31 31 0.74 0.68–​0.80 24.4% 15 of 24 Probable decreases risk Strong
(63%)
Esophageal 13 14 0.57 0.42–​0.78 84.4% 4 of 8 Limited-​suggestive Strong
(50%) decreases risk
Kidney 24 30 0.83 0.72–​0.95 70.7% 4 of 20 N/​A Strong
(20%)
Lung 36 44 0.75 0.69–​0.82 80.3% 10 of 14 Limited-​suggestive Moderate
(71%) decreases risk
Ovarian 28 30 0.87 0.77–​0.98 64.7% 10 of 16 N/​A Limited
(63%)
Pancreatic 27 36 0.83 0.76–​0.91 35.6% 5 of 17 N/​A Limited
(29%)
Prostate 67 67 0.94 0.89–​0.99 68.0% 18 of 43 N/​A Limited
(42%)
a
WCRF/​AICR rates physical activity as convincing decreases risk for premenopausal breast cancer and limited-​suggestive decreases risk for postmenopausal breast cancer. Our
estimate represents an overall breast cancer risk.
b
PAGAC grade based on “colon” cancer specifically.
CHAPTER 3 Physical Activity, Sedentary Behavior, and Cancer 23

domain-​specific association between physical activity and colon Self-​reported questionnaires were the primary assessment methods
and rectal cancer incidence.5 Estimates pertaining to recreational used to capture data on physical activity in these studies; however,
physical activity and cancer risk were 0.80 (95% CI: 0.71–​0.89) and the validity and reliability of these questionnaires vary considerably
0.87 (95% CI: 0.75–​1.01) for colon and rectal cancers, respectively. across different instruments. For instance, the domains (i.e., occupa-
Occupational physical activity had slightly stronger effects with risk tional, household, recreational, transport), parameters (frequency,
estimates of 0.74 (95% CI: 0.67–​0.82) and 0.88 (95% CI: 0.79–​0.98) intensity, duration), and time periods (current, past year, lifetime)
for colon and rectal cancers, respectively. Statistically significant as- for physical activity assessment differ by study. Furthermore, dif-
sociations were not found for household physical activity and cancer ferent observational epidemiologic study designs have been used to
risk for either site.5 capture physical activity either retrospectively (i.e., in case-​control
Within each included study presented in Table 3.1, we examined studies) or prospectively (i.e., cohort studies) in relation to cancer di-
whether or not dose-​response associations between increasing phys- agnosis with consequent differences in the possibility of recall error
ical activity volume and reduced cancer risk have been investigated. that can influence the magnitude and precision of the estimates.
The most evidence of a dose-​response relation between increasing
levels of physical activity and decreasing risks for cancer was found Sedentary Behavior and Cancer Risk
for lung, colorectal, endometrial, and ovarian cancers, for which Sedentary behavior is defined as all waking behaviors with an en-
>60% of studies that investigated these trends found statistically sig- ergy expenditure ≤ 1.5 METs in the sitting, reclining, or lying pos-
nificant inverse associations. Evidence of a dose-​response effect for tures.7 Common sedentary behaviors include watching television
these cancer sites provides further support for causal associations. and video game playing (classified as leisure/​recreational sedentary
The findings pertaining to physical activity and cancer incidence time), sitting and working at a computer (classified as occupational/​
from the 2018 update of the WCRF/​AICR2 as well as the 2018 workplace sedentary time), and sitting in a car (classified as trans-
Physical Activity Guidelines Advisory Committee (PAGAC)6 are portation/​commuting sedentary time). Although increases in total
also presented in Table 3.1. While our results consistently support physical activity participation (especially ambulatory, spontaneous
the WCRF/​AICR findings, there were several cancer sites for which activities) may lead to reductions in sedentary time over a 24-​hour
we found considerable evidence for an association between phys- period, it is important to recognize that sedentary behavior and
ical activity and cancer risk that were not included in the WCRF/​ physical activity participation are distinct entities.3 Specifically, high
AICR 2018 report since that report was focused primarily on the ev- sedentary time is defined as “too much sitting,” whereas physical in-
idence from prospective cohort studies, whereas we included all ob- activity is defined as “too little exercise.”3 It is thus possible for an
servational epidemiologic research conducted to July 2019. Prostate individual to achieve or exceed physical activity recommendations
cancer, for example, has nearly 70 studies that have investigated the but also spend long, uninterrupted amounts of time sitting at work
association between physical activity and cancer risk; however, it has or at home. Conversely, a person may have a physically demanding
not been appraised by the WCRF/​AICR. Given the evidence that we job with little sedentary time (e.g., construction worker, cashier),
found in our review, prostate cancer would likely receive a classifi- but also no or low recreational physical activity participation. The
cation of “limited-​suggestive decreased risk” since the effect found American Institute of Cancer Research recognized the importance
is statistically significant and the overall magnitude of this effect is of considering both the amount of time dedicated to physical ac-
small (6% reduction of risk). Other cancers that have yet to be ap- tivity and time spent in sedentary behavior for cancer prevention
praised by the WCRF/​AICR include bladder (16 studies), kidney (24 and developed an educational infographic to illustrate these con-
studies), ovarian (28 studies), and pancreatic (27 studies). PAGAC cepts (Figure 3.1). This infographic illustrates the importance of
grades were similar to our summary estimates. The PAGAC con- making time for physical activity and breaking up sedentary time.
cluded that there was “strong” evidence that greater amounts of A meta-​analysis published in 2014 that included 17 prospective
physical activity are associated with reduced risks of developing studies and 18,553 cases reported that the highest levels of seden-
bladder, breast, colon, endometrial, esophageal, and kidney cancers tary behavior were associated with an increased risk of 1.20 (95%
and that there was “moderate” evidence for lung cancer and limited CI: 1.08–​1.53) in combined cancers compared to the lowest levels
evidence to suggest that increased physical activity was associated of sedentary behavior.8 Furthermore, a recent narrative review3
with a decreased risk of ovarian, pancreatic, and prostate cancers. summarized the current epidemiologic evidence on the associ-
ations between sedentary behavior and the risk of specific cancer
Heterogeneity sites. This review suggests that sedentary behavior is most strongly
We also examined the level of heterogeneity in the pooled summary associated with colon, endometrial, and lung cancers.3 Specifically,
estimates presented (Table 3.1), which were high, suggesting that high versus low levels of sedentary time were consistently associated
the variations in effects between studies are not due to chance. There with a range in effect estimates of 1.28–​1.44 for colon cancer.3 One
are different types of heterogeneity, such as clinical and methodo- meta-​analysis9 also specified that the association between seden-
logical heterogeneity, that may be contributing to the overall levels tary behavior and colon cancer remained after adjusting for physical
found in the pooled summary estimates. Related to clinical hetero- activity (risk ratio [RR] = 1.31; 95% CI: 1.21–​1.42) and stratifying
geneity, there may have been differences in populations or outcome according to sedentary behavior domains (occupational sedentary
definitions, though these factors were unlikely to be major sources behavior: RR = 1.30; 95% CI: 1.20–​1.40; recreational sedentary be-
of heterogeneity given the high degree of certainty in the evidence havior: RR = 1.32; 95% CI: 1.17–​1.49). A different meta-​analysis also
regarding most cancer diagnoses. Methodological heterogeneity conducted a dose-​response analysis and observed a 1.08 increased
was likely the largest contributor, primarily given the differences in risk of colon cancer (95% CI: 1.04–​1.11) for every two-​hour increase
physical activity assessment tools that exist across different studies. in sitting time per day.10 Similar to colon cancer, a range in the effect
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CHURCH REFORM:
THE ONLY MEANS TO THAT END,
STATED IN A LETTER TO Sir ROBERT PEEL,
Bart.
FIRST LORD OF THE TREASURY, &c.
By Richard Carlile.

TO WHICH IS PREFACED A CORRESPONDENCE

WITH THE BISHOP OF LONDON ON THE SAME
SUBJECT.

CONTENTS

PREFACE.
LETTER TO SIR ROBERT PEEL
PREFACE.
CORRESPONDENCE WITH THE BISHOP OF
LONDON,
IN 1833, ON THE SUBJECT OF A REFORM IN
THE CHURCH.

"To the Right Reverend Father in God, the Lord Bishop of London.
"62, Fleet Street, November 18,1833.
"My Lord,
"I have long and deliberately thought, that the state of the
Country, the state of the Church, and the state of the Public Mind in
relation to the Church, calls upon me to offer myself for an interview
with your Lordship, as my Diocesan, that your Lordship may hear
from me what I have to advance against the present state and
condition of the Church, and what I have to propose as an
immediately necessary and proper Reform.
"I offer to wait on your Lordship, with your Lordship's consent;
and promise, that my conversation shall be altogether courteous and
reasonable.
"I am one of your Lordship's scattered sheep, wishing for the fold
of a good shepherd,—(which is Christ Jesus),—
"RICHARD CARLILE."
"P. S.—I may add, my Lord Bishop, that I am altogether a
Christian; save the mark at which superstition has been planted
upon Christianity."

"Fulham, November 20,1833.

"Sir,
"I have to acknowledge the receipt of your letter, in which you
propose an interview with me, for the purpose of making known to
me your opinions respecting the present state of the Church.
"I beg to say, that I shall be ready to receive, and to give all due
consideration to any communication which you may think proper to
make me in writing; as being, on many accounts, a more convenient
method than that of personal conference.
"I remain, Sir,
"Your obedient Servant,
"C. J. LONDON."

"To the Right Reverend Father in God, the Lord Bishop of London.
"62, Fleet Street, November 24,1833.
"My Lord Bishop,
"In answer to my proposal to meet your Lordship in conversation,
on the state of the Country, the state of the Church, and the state of
the Public Mind with relation to the Church, your Lordship has
encouraged me to write what I have to say, and has promised to
receive it and to give it due consideration. I write as early as my
circumstances have afforded me the necessary leisure and
composure of mind.
"The first point to which I beg leave to call your Lordship's
attention is—that there is a very numerous degree of dissent from
the Established Church among the people of this country.
"The second point is, that this spirit of dissent has led to a very
extended opposition to the support of the Church in its fiscal claims.
"The third point is, that there is a preparation of a public mind
going forward for the putting of the present Established Church on
the same footing as the present Establishments of the Dissenters—
the footing of voluntary rather than legal support; and that the
preparation of this state of mind is accelerated by the embarrassed
state of the country.
"The evidence of these three points in prospect is, that the
present state of the Church will be entirely overthrown in the course
of two or three Sessions of Parliament.
"On the principle of dissent from the Established Church, I have to
observe, that it is desirable there should be no dissent; but then the
Church should be invulnerable. There can be no popular dissent
from any Institution that can be defended as good and best; and
though I am instructed to allow that the general body of dissenters
from the Church have dissented on very frivolous, even on
indefensible grounds, (inasmuch as the Dissenters have not
corrected in themselves the errors of the Church), there still remains
the proof that where the Church has been assailed or dissented
from, it has not been in a condition to defend and justify itself.
"This incapability of the Church to defend and justify itself, where
assailed, must have arisen from a defective state of its doctrine and
discipline.
"This doctrine and discipline is founded upon the literal reading of
the Sacred Scriptures, or the books of the Old and New Testament.
"I impugn the literal as an erroneous reading: it claims to be local
and temporal history, and is not. Not one of its apparent historical
subjects can be verified. Every one of them can be falsified, upon
the principle that other things were being done at the time, and that
other people dwelt in the places; and that nothing of contemporary
character, purporting to be history, has corroborated the historical
claims of the Old and New Testament.
"It is said of the writings of the Old and New Testament, that they
are allegorical, and that they contain the moral of human salvation
from evil. Under this view, they may be true, and may be important
as a matter of instruction. I so believe them to be true, and to be
important as a matter of instruction; but as your Lordship may put
me on the task of mentioning some particular facts and grounds on
which I impugn the literal reading of the Sacred Scriptures, and may
properly suggest that it is necessary this ground should be first
cleared before we try them on the other ground, I submit, as two
well-weighed and conclusive propositions:—
"1st. That the person of Jesus Christ, or the name, is not in
mention by any author of the first century, if the passage in
Josephus be excepted as an interpolation; and that this defect in the
evidence is fatal to the historical claim.
"2nd. That the people called Jews, or Israelites, neither formed
colony nor nation in that part of the earth which is now called Judea,
or Holy Land, before the time of Alexander of Macedon;
consequently all that is said of their dwelling in and going out of
Egypt, their sojourn in the Wilderness, their warfare with the
Canaanites and Philistines, their occupation of that country, their
subsequent conquest, captivity, and restoration, is entirely fiction or
allegory.
"I read it as political and moral instruction veiled in allegory \ and
as it is to be desired, that, in the removal of a system, all its defects
be made apparent, so it becomes a desideratum, that we account
for the origin of the sects named Jews and Christians.
"This may be done in two ways—-one, that they were public
philosophical sects; the other, that they were degrees of order in the
ancient mysteries.
"The moral of the allegory belonging to each is throughout the
same, and is an encouragement to the resistance and overthrow of
the tyranny of man, when it appears in the open authority of a King,
or in the covert authority of a Priest; and the preparing of a people
to do this, and the doing it, is precisely what is meant by human
salvation,—which is a sure and certain salvation from earthly evils.
"The absence of a proof of personal identity in the characters
sketched in the Old and New Testament, is the presence of proof (if
utility of any kind there be in the form of the allegory), that the
persons mentioned are like what all the gods and goddesses of
ancient religion were—personifications of principles, either physical
or moral, or both.
"In so receiving the Scriptures of the Old and New Testament, I
find them pregnant with the most important political and moral
instruction. In receiving them according to the literal or historical
reading, I find difficulties insuperable, and such as justify all that
Thomas Paine or any other straightforward critic has advanced on
the subject, while the moral and the allegory were concealed from
their view.
"The point at which this personification of principles begins, is the
point at which superstition begins; for though knowledge may justify
the poetic licence taken with language, ignorance mistakes and evil
design misrepresents, until the personification is extensively dwelt
on as a reality.
"Here I trace the fundamental errors of the present doctrine and
discipline of the Established Church; the errors upon which dissent
has progressed, upon which an outcry of infidelity has been raised,
but upon which the Church could not defend itself and maintain its
position.
"My remedy for the present difficulties, and my proposition \ for a
Reform in the Church is, that no difficulties, mysteries, or
superstition be allowed to remain attached to its doctrines and
discipline; that the allegory of the Sacred Scriptures be avowed, the
personifications taught upon their principles as known principles of
nature, and not as personified incomprehensibilities; that the
Church, in short, be made a school for the people, than which, if it
originally meant any good thing, could mean no other thing, where
from time to time all acquired or acquirable knowledge should be
taught. On this ground, the utility of the Institution is evident, the
benefit to the people certain, the idea of dissent inadmissible.
"In this first letter, I have thought it necessary only to give your
Lordship the leading points of objection to the present doctrine and
discipline of the Church. With details in proof, I can proceed to a
voluminous length; and I now offer myself to submit to the
catechism of your Lordship, or to that of any person whom your
Lordship shall appoint to see me, with the distinct promise, that I
will not evade the giving of a direct answer to any distinct and
intelligible question that can be put to me upon any part of this
important subject.
"It may not be improper that I now declare to your Lordship, that,
after having worn out the spirit of persecution by a large amount of
personal and pecuniary suffering, I have never been acting upon any
other motive than a love of truth, and honesty, and public good; that
it is under such a motive, and no other mixed motive, that I have
now presented myself to your Lordship, viewing your Lordship as a
public functionary that has inherited and not created the error of
which I complain; and hoping that I shall be met with the disposition
of a fair investigation, when so much good is at this moment the
promised consequence,
"I am, My Lord,
"Your Lordship's most obedient humble servant,
"RICHARD CARLILE."
LETTER TO SIR ROBERT PEEL

Sir,
I write as a politician to a politician, with oblivion of the past,
without any profession of respect for the present, waiting and
watching your future.
I am stimulated to address you, and the country through your
name, on reading your Address to the Electors of Tamworth, after
taking the offices of First Lord of the Treasury and Chancellor of the
Exchequer.
The portion of your Address which I select as my subject, is that
relating to the Church—the first of all political subjects. Not to
understand how to deal with this, is to be utterly deficient in every
other political branch. Not to reform this, is to reform nothing. State
ever did, and ever will, depend upon the Church.
As far as your individual promise is sufficient, it is, that Church
Rates shall be abolished. This is so far good. It has been a disgrace
to all parties concerned, and an injury to every housekeeper, that a
Church Rate has existed. Such a rate has existed only because of the
dishonest application of that Church Property which was the
legitimate supply for all Church Buildings and repairs. And should the
rate be continued under any other form of taxation, and not supplied
from existing Church Property, an injury and an injustice will still be
inflicted upon the people.
You seem willing to abate the religious ceremony of marriage, so
far as to allow each couple to let it be to its liking. Pray go a step
farther, and let the law cease to trammel that civil contract with
religious ceremony, while each couple will be at liberty of its own
accord to go through whatever religious ceremony it may think
proper. And while on this subject, I pray you to give, or seek for the
poor, justice in facile divorce. The mystery of marriage is too sacred
for constraint. It should never be other than a spirit of pure and
mutual liberty and consent, subject to some legal recognition for the
care of offspring. Much of the morals of society must depend on the
freedom of marriage and facility of divorce. We have not hitherto
been right on this subject. That can be no good tie which opposes
the will of an individual in so sacred and delicate an affair as that of
marriage. The beginning, middle, and end of marriage should be the
love of affection and friendship. Marriage should cease when
affection between the parties has ceased. It may be truly added,
that marriage has morally ceased, when affection has ceased. Then
the legal tie becomes an abomination, a source of vice and wrong;
and, in nine cases out of ten, the religious ceremony is treated as a
burlesque, save the idea, that it is a fashionable distinction to have
observed it as the chief criterion of legal marriage.
I entirely agree with you, that Church Property should not be
alienated from strictly ecclesiastical purposes. I have changed my
view, and see more than formerly on this head.
For the same reason, I entirely disagree with you on any
commutation of tithes. Let the original application be restored, and
no one will find fault but he who loses by that just principle, that
first and best of Church Property and most important of popular
rights.
The point, in your address, on which my letter is to be based, is
the following paragraph:—
"With regard to alterations in the laws which govern our
ecclesiastical establishment, I have had no recent opportunity of
giving that grave consideration to a subject of the deepest interest,
which could alone justify me in making any public declaration of
opinion. It is a subject which must undergo the fullest deliberation,
and into that deliberation the Government will enter with the
sincerest desire to remove every abuse that can impair the efficiency
of the Establishment, extend the sphere of its usefulness, and to
strengthen and confirm its just claims upon the respect and
affections of the people."
This is just what I wanted you to say. It is honest, if you will but
act up to it. This is the sort of Church Reform that I propose. Here
we have from you, as the Chief Minister, a promise that your
Administration will enter into the fullest deliberation, with the
sincerest desire to remove every abuse that can impair the efficiency
of the Church Establishment, extend the sphere of its usefulness,
and strengthen and confirm its just claims upon the respect and
affections of the people. Had I been called to your situation, I could
not have promised more; but I should have acted up to that
promise, and I hope you will so act. In the performance of that
promise, everlasting fame will be yours. So act—and greater than
the name of Lycurgus or Solon—greater than that of Cicero,
Constantine, or Napoleon—greater than the name of any past man
will be that of Robert Peel. If the Duke of Wellington join you in this
sentiment, and goes manly and honestly forward to its
accomplishment, his, too, will be an imperishable name. This would
wreathe him an evergreen chaplet, that would survive the memory
of all his physical victories! This is the great moral victory to be
obtained before any society can settle down into peace, welfare, and
happiness:—the best use that can be made of the Church. It is a
subject of the deepest interest; it requires grave consideration; I
pray that it may have that consideration. I pray that I may be heard
by a Commission, in grave consideration of that subject of the
deepest interest, before any legislative change be entered upon. I
put myself forward in this letter. Many will be the schemes proposed
to your consideration: let mine be one, and then select and improve
the best.
The first consideration is—What is now the Church? What are its
defects? What the cause of that dissent, which has made a revision
necessary?
The second consideration will be—What ought the Church to be,
so as to leave no ground and reason of dissent? To some minds, the
fickleness and fallibility of human nature will appear as an
insurmountable obstacle to the construction of such a Church. I see
farther and will propose in order.
I flatter myself that I am writing this letter with very proper
feelings toward all institutions and all persons. I suspend, pro tem.,
all quarrels that I have with all men, to assist you in this common
good, in which you deserve and will have, in the ratio of their
goodness, the assistance of all good men. If I can sink the past in
oblivion for common good, who should say he cannot? To the altar
and shrine of that Reformed Church, which you contemplate, I have
sacrificed property much—all I had, and years of liberty many. I am
still worshipping, still so sacrificing, both property and personal
liberty, and will so continue to the end. I say it not boastfully; but in
comparative claim to attention, and in encouragement and example
of union to assist you in the performance of your present promise.
Let me be permitted to say, too, that the Church is a subject
which I have studied in its origin, its history, its first principle, all its
dissent or variation from that first principle, down to its present
standing. I have so studied it, that I cannot now find author or
preacher who can present me any thing new as to its general merits,
past or present. This is the chief ground on which I solicit your and
the public attention to my view of this subject of Church Reform. I
presume to know what the Church is, and what it ought to be.
It may be taken as a point to be yielded by all parties, that the
desire with regard to the Law Established Church is, the removal of
all ground of dissent, so as not to leave it a mere sectarian Church,
which any mere abatement of existing dissenting objections will do.
No Dissenter can complain, if the ground of his dissent be removed
from the Church. And if there be no ground of future dissent left,
there can be no future complaint, no new dissension arising. Without
the absence of the possibility of dissent, there can be no just holding
and application of a public and common property for the business of
the Church. With that absence, the property is justly held and
applied. Any law that recognizes and tolerates the Dissenter,
recognizes and tolerates the justness of his dissent, and calls for the
primary justice of removing the ground of dissent. No man can
reasonably say, let us not be of one Church; but every man can
reasonably say, let the Church be purified of its errors; and while any
man can show an error, it is his duty to call for the purification, and
the duty of authorities to attend to his call and to purify. A
permanent Church then must be an improving, self-purifying Church,
and continue a true picture of the best state of the human mind,
meeting every well-founded and majority-decided call upon its utility.
Any idea of keeping up a Law Established Church with public
property, surrounded by Dissenting Churches, without a public
property, can enter the head of no man who understands the
subject. There can be no peace or final settlement under such an
arrangement. The effect to be accomplished is, not to break up the
Church Property; but to break up the Dissenters from the Church.
This will startle the present state of mind and feeling. I propose no
abridgement of equal liberty. Is not this the grand desideratum? Can
it be accomplished?—I think it can, and so proceed to unfold the
two-fold consideration.
First.—What is now the Church? What are its defects? What the
cause of that dissent which has made a revision necessary?
This, in reality, is but one question, with a three-fold expression.
The Church is now the Theatre of the Drama of the Books of
Common Prayer, the Thirty-nine Articles, and the Old and New
Testament; to which is generally added a sermonic epilogue or
exhortation, commonly called a Sermon.
Be not offended at my use of the word Theatre here: no other
would substitute. Its root is the Greek [———], God, and signified
originally, the house, place or stage, where the Drama of Theism or
attributes of Deity were exhibited. The word is now much distorted
from its root, in being made to describe the place of modern
dramatic performances.
Nor must the word Drama be objected to; because the ceremony
of the Church was originally so constructed, so meant, and so
practised, as I will prove in the course of this letter.
Even the word Tragedy has its root in the Greek word [———], a
goat, and signifies, in the dramatic exhibition of Theism, the death
of the year, under the form of a personification, in the twelfth or
zodiacal month of the goat. So that the death sorrowed for and
lamented, was, dramatically, the apparent death of the sun, the
death of the year, in the sign or month of the goat; and on St.
Thomas's day, as we read in the Prophet Ezekiel, chap. viii. v. 14
—"and behold there sat women weeping for Tammuz;" and v. 16
—"about five and twenty men, with their backs toward the temple of
the Lord, and their faces toward the east; and they worshipped the
sun toward the east," which is no other than a representation of the
performance of the tragedy, in which the performers had lost the
moral of the Lord's Temple: precisely the present state and condition
of the Church. All ancient mythology is in harmony with this
conclusion; and the Christian tragedy is only a continued version,
uniting the general drama of human morals with the annual tragedy
of solar physics, and forming a two-fold or two-keyed allegory or
mystery, physical and moral, as it was known even in the Celtic or
Druid Church. Christianity was never new, or young, in this country,
by existing records.
There are not many persons in this secret, perhaps, not even you,
the first Minister of the country; so it will be deemed too abstruse
and mystical on which to find a warrant for legislation or change of
law: but I strenuously maintain, that such was the origin of the
Christian Church, and such is now its generally lost meaning. The
proof of the solar part of the allegory is not so much to my present
purpose as the proof of the general drama of human morals being
the basis of the present mystery of the Christian Church.
To stay a growing difficulty, we must go to the root:—it will grow
again, if we do not go to the root. It will be so with the present
Church, and all attempts to reform it.
In plainer language, then, I will describe the existing Church, as
having, in its ceremonies and business, the mystery of the Christian
Religion, without its revelation; that all the defects and all the
grounds of dissent from it are the absence of the revelation, or want
of knowing the meaning of the mystery. Whatever are called its
doctrines, are all mysterious; its discipline is equally mysterious, and
by its present ministers, unaccountable. Dissenters have dissented
without being able to assign a reason for their dissent, and have set
up for themselves something equally mysterious and unaccountable;
and so the whole principle and practice of Religion in the country is
in confusion and conflict; and no measure can reconcile the
dissentients, short of developing the first principles of the Church
and the Christian Religion, the one language, the one course of
reason, the one ground of human welfare, the one system of morals,
which is now buried in a Babel of confused tongues, doctrines, idol-
houses, and superstitious ceremonies.
The ground, then, on which I proceed, is, that TO REFORM THE
CHURCH, THE DISSENTERS MUST BE ANNIHILATED.
Not annihilated by slaughter or physical force; but by superior
knowledge, and consequent superior teaching, by openness, by
honesty, by throwing off the mask of hypocrisy, and leaving the
Church of Christ to be no longer a theatre of dramatic ceremony in
mystery, with parts and actors as ignorant as automata of their
subject, and who not knowing, can value it not, beyond the salaries
they receive for its performance in unrevealed mystery.
Can that be a Reform of the Church, with "just claims upon the
respect and affections of the people," which shall leave a ground
and excuse for dissent by any one of the people? I say, NO. Can it
be a Church of Christ? I say, NO. Do we know what a Church of
Christ is in reality? For myself, I say, YES. A Church, too, founded
upon an understanding of the Sacred Scriptures, of the Old and New
Testament, upon the revelation of the mystery of those Scriptures,
and upon all the first principles essential and conducive to general
human and social welfare; that shall no more admit of dissent than
the multiplication table, or the accurately placed sun-dial, than the
elements of Euclid, and all the never-failing tests of the science of
chemistry. The Apostle that told us to "prove all things, and hold fast
that which is good," gave us a definition of the exhortation of the
Evangelist or the Baptist—"Repent, for the kingdom of Heaven is at
hand." A repenting and a proving people are necessary to make a
Church of Christ. Repentance and enquiry are the pillars and
foundations of that Church; without repentance and enquiry there
can be no Church of Christ; and I ask, confidently ask, with the
assurance that a true answer must be in the negative,—has anything
calling itself a Christian Church in Europe, established by law, or
dissenting from such an establishment, anything to do with the two
principles of repentance and proving, the one meaning reflection by
animadversion, the other a trial by outward tests of that reflection?
There is not a congregation of people in Europe, calling itself a
Church, that is founded upon an understanding of the Sacred
Scriptures, the understanding which shows that the "letter killeth,
but the spirit giveth life."
I impugn, as being in error,—I denounce, as that error is the cause
of all dissent, of dissent uninstructed,—all the churches or
congregations called churches in the British dominions; and I call for
a reform that shall eradicate that dissent, and make all become one
in efficiency, usefulness, and respect and affections of the people.
The present state of the Church is, that it is a theatre of mystery,
giving no solid satisfaction to the people, and for which, among the
receivers of salaries and benefits only, can there be a particle of real
respect and affection. Its defects are, that none understand, neither
priests nor people understand what any part of its dramatic
ceremonies mean. And this is the cause of that dissent which has
made a revision necessary.
What, then, ought the Church to be, so as to have no ground and
reason of dissent?
In two words, I answer, A SCHOOL.
What kind of a school?
A school for knowledge only; for revelation without mystery; and
for practical use and benefit to every member, without parade or
pomp, even without ceremony, beyond what order and good may
require.
And would such be a Church of Christ?
Such alone can be a Church of Christ. Christ the Logos, Jesus the
Saviour of Man, is, in principle, nothing more in its dramatic or
mystified and present church presentation, than a personification of
the principle of reason, or of the knowledge of which the human
being is a recipient, and without which can have no salvation, has no
relation to the idea of a salvation, or any evil from which to be
saved. Such is a true revelation of the mystery of Christ.
And a Church of Christ has no other true meaning, than a
convenient and sessional gathering of the people in districts, for
purposes of mutual enquiry and mutual instruction; for catechism
and intelligible and useful exhortation; for revelation of knowledge,
or mind, or reason; for mental improvement; and not for mystery,
nor dramatic ceremony, nor superstition, nor idolatry. It is in this
sense only, that the Church of Christ is superior to all other Churches
—the word Church meaning a gathering or association of the people
for mental improvement.
This generation has no proof, nor has history a warrant, that any
other generation of man has had a proof of the material existence of
the being called Jesus Christ. The seeming narrative of such a
purport is the current mythology of the ancients, or people of two
thousand years ago, taken up by us in its literal sense, and so
mistaken; so mistaken, as to warrant a belief in the literality and fact
of the material, temporal, and local existence of every one of the
Gods of the Pantheon, or of human imagination, and then we shall
have rivalry enough for the best. But then, I should make a choice of
Christ, as the only one that makes due provision for the right
cultivation of the human mind; the only one that has laid the
foundations of the kingdom of Heaven, in the peace and good-will of
mankind, dwelling upon a land flowing with milk and honey, and
overflowing with knowledge.
I challenge the Bishops and the whole priesthood, to produce me
any knowledge that is intelligible to themselves or to any other
person, as an interpretation of the narratives in the Old and New
Testament, about Jehovah or Christ, other than that which I am now
unfolding. Mine has a warrant in the spirit of the language of the
books, in the roots of words, and in all the principles of things that
relate to man's welfare; and more particularly in that to man most
important of all, MORAL SCIENCE.
I am not insensible to the circumstance, that a man might have a
knowledge of a thing, of a train of circumstances, of causes and
effects, in his own mind, with a difficulty to find language in which to
communicate it, that shall be equally and immediately clear to all
other states of mind. A resemblance, nearness, or similarity of mind,
almost an equality of knowledge, is requisite to a clear
understanding. It is thus, that men, in different languages,
understand each other, when other men, bystanders, do not
understand them. And it so happens, in all first developments of
science, the new discovery wants a new language in which to be
presented to others, and it often happens, that first words made or
chosen are not the best and clearest.
Know you not, Sir, that knowledge is power? You must have read
that celebrated axiom of Bacon's; but have you considered it, have
you reflected, have you repented and proved that axiom? I may add,
by way of explanation, that knowledge is the only moral power.
What seeks your Church to be? Or what should it seek to be, other
than a moral power? On what rock, then, must the Church of Christ
be built, so that the gates of hell, or of evil design, or of dissent,
may not prevail against it? On what, but KNOWLEDGE? Is it now so
built? Is not, rather, the present ministry of the Church more afraid
of knowledge than of the people's ignorant dissent; more of "Carlile
and his crew," than of all the dissenters; more of free discussion,
than of any kind of superstition? The dissent of knowledge and the
dissent of ignorance, though disunited, are becoming too powerful
for your knowledgeless Church; and you, at last, have consented to
speak of its necessary reform! To which will you yield, or whom will
you join? Those who dissent by knowledge, or those by ignorance?
If you take the former, your work will be perfected at once; if the
latter, your work will never be done, and you will become weaker
and weaker; for I know not one body of worshipping associated
dissenters, whose ground of association and dissent is better than
that of the Established Church. Find me the minister of one of them,
who will stand up in discussion before a public audience with me, so
as to have his language reported. I have not yet found him in
England or Scotland. The pretences of the kind that have been
made, have been so deficient in respectability of character and of
good manners, that I do not think them worth a recognition.
I am not insensible to the circumstance, that you have a difficult
task to perform, and I am not sure that you are equal to it: I hope
you are; that is, I would have you so, or any other who may be the
King's adviser, and the real head of the Church. Nothing is wanted
for this reform but honesty and moral courage. Where the will and
the power exist, the task is an easy one. I desire to save the Church
and its property, and to annihilate the Dissenters. I would have the
present dignities of the Church dignify themselves in a triumph over
the Dissenters. A collusion with the Dissenters will be a hugging of
pestilence and death to the bosom of the Church. There can be no
co-existence: there was proof enough of that in the seventeenth
century, and still in Scotland. A revolution in the affairs and manners
of the Church must take place, even by your own confession, in
language admitting of the inference; and I desire that good may be
educed from that revolution. I would make the Church triumph in
the correction of every mental error in the country, and noble would
be that triumph!
You may ask, how is this to be done? I will tell you. Let the Church
become the oracle of truth, the fountain of knowledge, the mistress
and dispenser of all science. Let its ministers declare this great truth:
—that, hitherto, the mystery of Christ has alone been taught in the
Church, without the revelation of that mystery; that the Church has
been the depository of that sacred mystery, until the fulness of time,
in which it is promised, that all people shall be prepared to partake
of the revelation; that the mystery has been kept up in outward form
and without any spiritual grace; that the spiritual grace and all the
pro-mises are to be fulfilled in the understanding of the revelation;
that the spirit or revelation has been buried in a resting on the letter
of the Sacred Scriptures; that Christ is only now risen or beginning
to rise, after thousands of years, we may say three thousand years,
rather than three days of crucifixion, death and burial. In me, he has
risen indeed, as, in me, he has been last crucified; and I crave the
pleasure of seeing his principles rise in the Church; for that craving
is the nature of Christ. Let the Church declare that the time is now
come to reveal the mystery of Christ. Exhibition has not been
revelation.
What, then, is the revelation of the mystery of Christ?
It is, that Christ is God and not man, that it is God in man; that it
is knowledge, reason, or all its essences in moral principle; and that
it is not an idol to be worshipped as a statue, but a principle to be
taught and inherited by the human race. The mystery sets forth
Christ as a statue or image to be worshipped after the fashion of the
Pagan world. The revelation teaches, that it is the principle of
knowledge, to be gained by labour, by asking, seeking and knocking,
or prayer; by repentance, that is, reflection; by enquiry, that is,
proving all things, and holding fast that which is good; by mutual
instruction, by free discussion, by whatever constitutes a school for
useful knowledge, and that constitution is a Church of Christ: all the
rest is mistake or imposture, whether it be established by law, or
ignorantly dissented from; whether it have a King for its head, or be
carried on in a garret or a cellar.
I must go to the root of my subject, and leave no excuse for
evasion. The root of religion is the relation of God to man, and man
to God.
What does man know of God?
Books can teach him nothing, unless those books be written
pictures of existing things and things that have existed. Things that
have existed have no source of trial or test, but in the similarity of
things that do exist.
Man's knowledge of existence is of a twofold nature: the things
that do exist, and the power by which he has that knowledge. The
first is distinguished as material existence; the second, as spiritual
existence. Material and spiritual existence are the only two positive
existences of which man can speak or write, to which no inspiration
can add; for inspiration is only knowledge; and the recognition of
material and spiritual existence is the limitation of knowledge. The
details of knowledge can be nothing more than definitions and
descriptions of existing things,—the plantings of art upon nature.
All knowledge is matter of art. Nature is the thing known—art the
knowledge of the thing. This art can not only know nature, but can
invent descriptions of unreal things; can describe things by types,
and principles by figurative allegories; can imitate nature by
appearances, such as pictures, statues, &c.; and can, by mysterious
constructions of language, make the appearance of a thing to
represent a principle or describe qualities in the absence of the
thing: this is spiritual power. Nothing of the kind is seen beyond
human life; certainly not beyond animal life. We may, therefore,
reasonably speak of spiritual power or spiritual existence as confined
to the human race—speech and language being a primary necessity
to its existence: the art of other animals extending not beyond their
wants.
Man, then, is the creator of spirit; and, beyond man, spirit is not
known. Man is not known to be the creature, but the creator of art;
not the creature, but the creator of spirit, soul, mind, reason,
knowledge, or whatever other term relates to the mental
phenomena.
I maintain, because it is a truth of the deepest importance to the
human race, and without the knowledge of which nothing can work
well in human society, that man is the creator of all spiritual
existence; and in the sense in which God is a spirit, man is the
creator of that God, and has been the creator of every description of
existence that has been made of such a God.
We may also correctly speak of this two-fold existence as physical
and moral. The physical, its forms and compositions excepted, is
eternal and immutable—the moral is evanescent, mortal, and
mutable in its personal existence, but immutable and immortal as to
principle. The root of God, therefore, as of man, is in physical power,
which is correctly described as almighty, immutable and
omnipresent: it is only omniscient, as being the fountain of
knowledge—the all that can be known. Science is art; therefore,
there can be no science in an infinite or eternal sense, as we can
speak of the physical power of Deity; but science, as art, is limited to
human power,—the all that is known, and not the all that exists to
be known.
This is evidence, that man has created not only all the descriptions
that have been made of spiritual existence, but that existence itself:
and so it is true, that man has been the inventor of a spiritual God;
that religion and all its appurtenances have been the offspring of the
art of man; and that man alone is capable of correcting any of its
errors,—which is to be done in the same way by which I propose to
put down the Dissenters—the acquisition and communication of
knowledge by the Church.
I pass by the Pagan mythology, which, in its understood
personifications and allegories, is as beautiful a picture of physical
and moral nature, as the Christian Religion itself; and I rest on the
Christian, as, when understood, the only religion for human
improvement that has been presented to the notice of the human
race.
As man is the inventor of the Spiritual Deity, which is peculiarly
the Deity of the Christian Religion, so I infer, by evidence to come,
that the Deity of the Christian Religion is no other, nothing more,
than a personification of the mental phenomena of the human race,
which was the work of the philosophers and scientific men of the
Pagan world: and noble was their task—important for man was their
production. Not the thing called the Christian Religion now in
existence, which is no other than a religion mistaken, a corruption
and Pagan superstition, the dregs and drivellings of the gross
ignorance and superstition of the dark ages; something two
thousand times worse than the Paganism of the Millenium before the
so-called Christian era. But a personification after deifications of the
mental phenomena, is a sounding, preaching, writing, carving or
painting God, as the perfection of knowledge; Christ, as the
perfection of reason; and the Holy Spirit of communication, as the
perfection of all attainable moral power by the human race: making
those perfections to be things sought, the things worshipped, the
best religion, as it undoubtedly is, for the whole human race. It was
the best plan of scholastic improvement, when acted upon, that
human wisdom could have devised, and to this I would have you
bring our Church.
There is a two-fold way of reading the Bible, which I have before
described, as it is described in the Second Epistle to the Corinthians,
chap. iii. v. 6, a reading or a ministration according to the letter, and
another according to the spirit. The Apostle or author of that Epistle
declares himself to have been a minister of the New Testament
according to the spirit, and complains, that the Jews, in his time, did
not know how to read the Old Testament. I declare that the Church
now existing ministers to nothing but the letter of the Bible, which is
a ministration not to life, but to death; and such is the evidence of
the whole era of such a ministration; such has been the cause of the
dark ages, on which no dissenting sect has yet thrown a ray of light;
and the reform that is now required throughout the Church, that
established by law and all others, is the understanding of the Sacred
Scriptures, that shall cause them to be taught according to the spirit,
the spirit of knowledge, reason and constant human improvement. I
now see, that none of the people called Jews or Christians know
how to read either Old or New Testament according to the spirit.
To read the Bible according to the letter, is to make it a piece of
human history; to make a creation of the world, and an attempt to
account for everything past, present and future. I proclaim this
conduct to be the folly of ignorance, opposed by all real history of
the human race, and by all the developments of science, in relation
to the earth's existence, its qualities, and its relation to the general
planetary system.
I challenge the proof of any one apparent historical fact, in either
Old or New Testament. I challenge the production of the existing
mention of any one of the supposed facts about the personal or
material Jesus Christ, within one hundred years of the time at which
it is said to have happened, putting the disputed passages of
Josephus and Tacitus out of the question.
I challenge the proof of the existence of the Jews, in any country,
as a distinct nation, before the time of Alexander the Great.
No other contemporaneous history recognizes such an assumed
history as that which I challenge.
And farther, I am prepared to prove that Christianity existed
among Romans, Greeks, Persians, Hindoos, and Celtic Druids, or the
northern nations, before the Christian era.
The present ministration of the Church entirely depends on the
necessity of a clear historical proof of the literal contents of the Old
and New Testaments.
But a spiritual reading of that volume solves every difficulty, and
teaches us how to extract the truth, the system of religion that is a
necessary and sure salvation for the human race, when reduced to
practice, and to see it as a part of the wisdom of all ancient men of
all times and countries.
It is ten years and upwards since I sent a petition to you, Sir, to be
laid before the King, asking for a commission to examine my
oppugnancy to the religion and administration of the existing
Church. Will you now grant that commission? If you will not, you,
while you remain in power, will blunder on in and through growing
troubles and difficulties, until you, or some other person, be
compelled to come to my school for information. It may be a galling
pain, a conscience-smitten task to you to do so; but you have no
alternative with honesty and wisdom. It is not a little of this cry for
Church Reform, that has sprung out of my labours and sufferings.
And here am I, though still in prison through that Church's iniquity,
in the proud and triumphant position, clearly seeing that you can
reform nothing in the Church that will satisfy the people without
coming to my ground.
Your pledge is so to reform the Church as to make it meet the
respect and affection of the people. I rejoiced when I read that
sentiment; for I saw and felt, that I alone had proposed a reform
equal to that end; and mine, as well as others, by the glorious
power of the printing press, must come into consideration. I assure
you that the correspondence with the Bishop of London, which I
shall append to this letter, has been sold to the extent of many
thousands, and is in great demand. This is but an enlargement of
my second letter to the Bishop. So that my lamp has been constantly
trimmed for your advent as a Reformer of the Church. It is not what
you and others call "the rabble," "the destructives," "the mob," that I
seek. I seek you and the Bishops, all the learned men in the country,
as in application of mind to mind, learning to learning, and wisdom
to wisdom.
I will now proceed to explain the distinction between the mystery
and the revelation of Christ, between the letter and the spirit of the
books of the Old and New Testament, between false and true
religion, between superstition and idolatry on one side, and reason
with growing knowledge in the Church on the other. I begin with the
doctrine of the Holy Trinity.
The Church of the dark ages has taught the doctrine professedly
founded upon the letter of the Sacred Scriptures: of God, as
consisting of three persons in one person, coexistent, co-equal, and
co-eternal, which, in expression, has been abridged, under the name
of Trinity, and described as the Holy Trinity; and, in definition or
distinction, as Father, Son and Holy Ghost. This doctrine has always
been dissented from while dissent has been tolerated. It is no more
a physical absurdity than the doctrine of the resurrection of the
dead, or the changing of water to wine, or the feeding of five
thousand with five small loaves and two fishes, or any other
narrated miracle: still it has been dissented from, and when
dissented from, no defence could be made of it. In every other case
of dissent, the Church could make no defence and no other apology
than ancientness of the doctrine in the Church. Truly this has been a
verification of the blind leading the blind, until both fell into the ditch
together.
With a doctrine of personality in Deity, including the ideas of
physical and moral power, this of the Trinity has been declared a
mystery incomprehensible to the human mind; and I declare that a
mystery incomprehensible to the human mind, pressed upon human
attention, as of importance, is an absurdity, and must be an
imposture; for who has comprehended it so to state? This is the
matter-of-fact view of the subject.
But the subject being a declared mystery in the theological sense,
there is a spiritual interpretation to be put upon the language of the
letter; and that I take to be thus:—
That the Trinity is not to be considered as of persons, but of
principles; and then we shall find it a philosophical doctrine, true to
nature, and proved by science; true to physical and to moral science.
All the ideas that physical science can bring us of creation is the
root of three in one. Whatever admits of analysis sets forth the truth
and doctrine of the Trinity. Water, the great parent of production on
this planet, is known to be composed of two gases—hydrogen and
oxygen. They become water through contact and decomposition by
electric action. Thus, in the order of a Trinity in Unity, we may
describe it as of hydrogen, oxygen, electric contact=water. I do not
mention this as any thing new; but it is new in application to a
definition of the doctrine of the Trinity. Water had not been made
but by the electric contact of hydrogen with oxygen, by the power of
a Trinity in Unity. Chemistry teaches us, that this power of a Trinity in
Unity is an all-creating power; and so far it is man's comprehension
of the creating power or Deity, and not a thing or principle
incomprehensible: it is a doctrine older than the Christian era; was a
doctrine among the Pagan Philosophers, and is true as to principles
or powers; but not true in our modern sense of persons, as identical
and separate beings.
A great mistake, too, has been made in the understanding of the
word person, in relation to theology: it never was meant to express
beings in the image of you and me; but the dramatic manner of
presenting a description of the principles of nature in the theatre,
per sonantem, by sound or song, by fiction, by disguise, by allegory,
by mask or mystery, by representative action: the revelation of
which would be to understand the principles of nature so personated
on the stage, as I have defined the Trinity. And it is in this, and no
other sense, that I read the names of Deity in the Old or New
Testament, as brought apparently on the stage of human affairs, in
person, by the authors; that personating meaning nothing more
than a present picture or representation of an absent or infinite
power, by sounds or voice, and sometimes by masks, as was the
earliest known practice in dramatic exhibition, which explains
everything about gods and oracles, and makes the Hymns of
Orpheus as sacred as the Psalms of David; as they are as certainly
beautiful in poetic composition, and equally useful to human welfare.
You, Sir, if you enter the House of Commons next month, may be
said to personate the Electors of Tamworth; a power in the abstract
greater than you, because many and supposed qualified to reject
your personation and to elect another. Therefore, the personation is
not the power personated. As the King's chief Minister, you will also
personate the King's Government in the House of Commons; but you
are not in reality that governing power; because, it is something
distinct from you, and greater than can be concentrated in your
person. You, as plain Robert Peel, and I, as Richard Carlile, are not
persons; and though it is a custom so to use the word and so to
describe us, yet it is a mistake and misuse of the word, unless the
body may be said to personate the mind, soul, &c. I hope you see
that much of the error of our Church has turned upon this point;
because a person was never the reality of the power, and
consequently the persons of the Trinity are not to be considered the
reality of the Trinity: and hence the Unitarian Dissenter has no
reasonable ground of dissent. The doctrine of the Trinity, as a
description of Deity, is a valid theological and philosophical doctrine,
admitting of no rational dissent.
I wish the Bishops to learn this before the Dissenters, so that the
Church may be taught how to call back her errant and ignorant
children, that her property may be held together for useful purposes,
and not be wasted at the shrine of dissenting ignorance or bankrupt
government.
And now, Sir, can you yet see your way with me, "to remove every
abuse that can impair the efficiency of the establishment; extend the
sphere of its usefulness, and strengthen and confirm its just claims
upon the respect and affections of the people?" If you cannot, I beg
you to follow me farther.
It is not only in physics that the doctrine of the Trinity is
theologically and scientifically correct, but in morals also; and this is
the foundation of the Christian Religion.
As God, the Father, personates all science, under the attribute of
omniscience; that is, personates all existence, both omnipotence and
omnipresence, and is, in that reality, the fountain of knowledge—the
all and every part that can be known; so God the Son, Christ or
Logos, personates the human mind, as the existence or
manifestation of knowledge and reason, as Jesus or the principle of
salvation from evil, in possessing that knowledge, and as the true
God, in us and with us, in and with whom we live, and move, and
have our being.
So God the Holy Ghost, the Spirit of Truth, the Comforter to come,
to complete the happiness of the human race, personates that spirit
of free communication of knowledge which should be found in the
Church, the theatre, not of any superstition or dramatic ceremony,
but of the freedom of the human mind, and all its emanations of
free enquiry, free discussion, mutual instruction, which are the
necessary elements of brotherly love and peace, in the proving of all
things and holding fast that which is good. And thus I prove the
truth of the doctrine of the Trinity.
This, Sir, is a true picture or effigies of the moral Trinity of the
Christian Church, which you will find to be a key to every mysterious
sentence of the Bible; and I ask you seriously, as between man and
man, is any thing of this kind known or practised in the present
Church? Are not the ministers of that Church afraid of every new
discovery in science? Have they not, as far as they could, persecuted
every man who has attempted to publish any criticism, enquiry, or
objection to their mysterious subjects? History says—Yes. And I say
that they have known nothing of the subject for themselves, and
that they have dreaded all knowledge of, all enquiry into, the
subject. Will their pride let them learn of me? Well may I say:
—"Come unto me, all that labour and are heavy laden, and I will
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